5/29/2024
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective July 1, 2024.
The following codes have been added on the Medicaid, Essential Plan, and Ambetter By Fidelis Care Metal-Level Products Authorization Grids and require prior authorization:
Q5137 ustekinumab-auub (Wezlana), biosimilar, subQ
Q5138 ustekinumab-auub (Wezlana), biosimilar, intravenous
J0911 Instillation, taurolidine and heparin sodium (hemodialysis)
J1748 infliximab-dyyb (Zymfentra)
J2267 Injection, mirikizumab-mrkz
J3247 Injection, secukinumab, intravenous
J3263 Injection, toripalimab-tpzi
J3393 Injection, betibeglogene autotemcel
J3394 Injection, lovotibeglogene autotemcel
J7171 Injection, Adamts13, recombinant-krhn
J7355 Injection, traveoprost, intracameral implant
J8611 Methotrexate (jylamvo)
J8612 Methotrexate (Xatmep)
J9361 Injection, efbemalenograstim alfa-vuxw
Evolent Oncology Program (New Century Health) will require review of the following codes for Medicaid, Medicare, Essential Plans and Metal-Level Products:
J2468 Injection, palonsetron hydrochloride (avyxa)
J3263 Injection, toripalimab-tpzi
J8611 Methotrexate (jylamvo)
J8612 Methotrexate (Xatmep)
J9361 Injection, efbemalenograstim alfa-vuxw
*Please note: Disregard the previous requirement for prior authorization for J0209, sodium thiosulfate (hope), effective 6/1/2024.
Visit: Authorization Grids