2024/6/27
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Posted by Provider Relations
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