10/28/2026
•
Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated.
The following section of the Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans, and Medicare Authorization Grids and requires prior authorization effective October 1, 2026:
III. Outpatient surgery: The following services require prior authorization:
D. Skin surgery and other dermatological procedures:
Only the following codes require authorization for any place of service: A2046, A2047, A2048, A2049, A2050, Q4207, Q4223, Q4243
V. Outpatient and DME Services: The following services require prior authorization:
A. Diagnostic testing:
Proprietary Laboratory Analysis: 0666U, 0668U, 0669U, 0689U, 0692U, 0694U, 0698U
The following codes have been updated on the Medicaid, CHP, Essential Plan, AmBetter Metal-Level Plans, and Medicare Authorization Grids and require prior authorization effective October 1, 2026:
C9311 eplontersen
C9312 trabectedin (apotex)
C9313 pivekimab sunirine-pvzy
J0463 leucovorin (NOS)
J0644 leucovorin (avyxa)
J1757 tividenosusp alfa-eknm
J1818 pegzilarginase-nbln
J1946 furosemide (lasix onyu)
J1947 furosemide (furoscix)
J3268 delafloxacin
J3406 omidubicel-onlv
J7524 mycophenolate mofetil, oral
J7529 mycophenolate mofetil, susp
J7530 mycophenolate mofetil (myhibbin)
J7531 prednisolone sodium phosphate ODT
J9066 bendamustine (avyxa)
J9186 etoposide (avyxa)
J9187 etoposide
J9191 fluorouracil (avyxa)
J9192 fluorouracil
J9362 trabectedin
Q5172 filgrastim-laha (filkri)
Q5173 denosumab-adet (ponlimsi)
For Medicaid, Essential Plan, AmBetter Metal-Level Plans, and Medicare, the following codes have been added to the list of drugs that require Evolent review effective October 1, 2026:
C9312 trabectedin (apotex)
C9313 pivekimab sunirine-pvzy
J0643 leucovorin (nos)
J0644 leucovorin (avyxa)
J9066 bendamustine (avyxa)
J9186 etoposide (avyxa)
J9187 etoposide
J9191 fluorouracil (avyxa)
J9192 fluorouracil
J9362 trabectedin
Q5172 filgrastim-laha (filkri)
Q5173 denosumab-adet (ponlimsi)
For Medicaid, Child Health Plus, Essential Plan, AmBetter Metal-Level Plans, and Medicare, the following code will require prior authorization and have been added to the list of drugs that require Evolent review effective December 1, 2026:
J7345 aminolevulinic acid topical
Visit: Authorization Grids