2024/6/27
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Posted by Provider Relations
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Provider News
The following sections of the Fidelis Care authorization grids have been updated effective August 1, 2024.
The following code has been added on the DME Authorization Grid:
E1815 Dynamic adjustable ankle extension/flexion device, includes soft interface material
Evolent Oncology Program (New Century Health) will require review of the following codes for Medicaid, Medicare, Essential Plans and Metal-Level Products:
J8999 iptacopan oral
J8999 tovorafenib oral
J8999 tovorafenib oral suspension
J9999 docetaxel (Docivyx)
J9999 tarlatamab
J9999 trastuzumab-strf injection
Evolent Oncology Program (New Century Health) will require review of the following codes for Medicaid, Essential Plans and Metal-Level Products:
J9393 fulvestrant (Teva)
Evolent Oncology Program (New Century Health) will require review of the following codes for Essential Plans and Metal-Level Products:
J9074 cyclophosphamide (Sandoz)
J9075 cyclophosphamide (not otherwise specified)
Evolent Oncology Program (New Century Health) will require review of the following codes for Medicare Products:
J9029 nadofaragene firadenovec-vncg
J9048 bortezomib (Fresnius Kabi)
J9049 bortezomib (Hospira)
J9056 bendamustine (Vivimusta)
J9058 bendamustine (Apotex)
J9059 bendamustine (Baxter)
J9063 mirvetuximab soravtasine-gynx
J9259 inj, paclitaxel proteinbound (American Regent)
J9322 pemetrexed (Bluepoint)
J9323 pemetrexed ditromethamin
J9347 tremelimumab-actl (Imjudo)
J9350 mosunetuzumab-axm (Lunsumio)
J9380 teclistamab cqy (Tecvayli)
Visit: Authorization Grids