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The following sections of the Fidelis Care authorization grids have been updated effective March 1, 2025.
The following codes have been removed from the Medicaid and Essential Plan Authorization Grids and do not require prior authorization:
J0739 cabotegravir inj
J0741 cabotegrvir and rilpivirine inj
J0750 emtricitabine tenofovir df, oral for PReP
J0751 emtricitabine tenofovir alafenamide, oral for PReP
J0799 unclassified FDA approved PReP drugs
J1746 ibalizumab-uiyk (Trogarzo)
J1961 lenacapavir (Sunlenca)
Q0521 Pharmacy supplying fee for HIV pre-exposure prophylaxis FDA approved prescription
S0104 zidovudine oral
S0140 saquinavir oral
Visit: Authorization Grids