5/1/2023
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective June 1, 2023.
The Medicaid grid has been updated as follows:
D. Skin surgery and other dermatological procedures:
- Only the following codes continue to require authorization for any place of service: 11200, 11201, 11719 (new code), 15769-15829, 17340-17999
The following codes have been updated on the Medicaid, Medicare, Essential Plan and Metal-Level Authorization Grids and require prior authorization:
C9145 aprepitant aponvie inj
C9146 mirvetuximab soravtansine-gynx inj (Elahere)
C9147 tremelimumab-actl inj (Imjudo)
C9148 teclistamab-cqyv inj (Tecvayli)
J0208 sodium thiosulfate
J0218 olipudase alfa-rpcp inj (Xenpozyme)
J1411 ertranacogene dezaparvovec-drlb (Hemgenix)
J1449 eflapegrastim-xnst inj (Rolvedon)
J1747 spesolimab-sbzo (Spevigo)
J9196 gemcitabine (Gemzar-Accord)
J9294 pemetrexed inj (Hospira)
J9296 pemetrexed inj (Accord)
J9297 pemetrexed inj (Sandoz)
Q5127 pegfilgrastim-fpgk inj (Stimufend)
Q5128 ranibizumab-eqrn (Cimerli)
Q5129 bevacizumab-adcd inj (Vegzelma)
Q5130 pegfilgrastim-pbbk inj (Fylnetra)
The following code has been updated on the Medicaid, Essential Plan and Metal-Level Authorization Grids and requires prior authorization:
J1729 hydroxyprogesterone caproate injection
The following codes have been updated on the Medicaid Authorization Grid and require prior authorization:
C9149 teplizumab-mzwv (Tzield)
J9314 pemetrexed inj (Teva)
The following codes have been updated on the Medicare Authorization Grid and require prior authorization:
C9149 teplizumab-mzwv (Tzield)
J1729 hydroxyprogesterone caproate injecton
Visit: Authorization Grids