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Fidelis Care Authorization Grids Effective January 1, 2025
11/26/2024 • Posted by Provider Relations

The following sections of the Fidelis Care authorization grids have been updated effective January 1, 2025.

 

The following codes have been updated on the Medicare, Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and require prior authorization:

III.       Outpatient surgery: The following services require prior authorization:      

            D.  Skin surgery and other dermatological procedures: 15011, 15012  

            H.  Eyelid & ocular surgery: 66683  

            Q. Urology: 51721, 53865, 53866, 55881, 55882&  

            R. Other: 60660, 60661  

  V.        Outpatient and DME Services: The following services require prior authorization: 

             A.    Diagnostic testing   

               4.  Gastroenterology Procedures: 42975        

            H.  Therapeutic Services:    

              3.  Pain Management Codes (i.e. injections, TENS, therapeutic services): 64466, 64467, 64468, 64469, 64473, 64474

The following codes have been added to the Medicaid DME Authorization Grid:

E0651

Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month

E0652

Electrode for external lower extremity nerve stimulator for restless legs syndrome

 

The following codes have been added to the Medicaid, CHP, Essential Plan, and Ambetter Metal-Level Plans Authorization Grids and require prior authorization:

J0601    sevelamer carbonate, oral, ESRD on Dialysis (Renvela)

J0602    sevelamer carbonate, oral powder, ESRD on Dialysis (Renvela)

J0603    sevelamer carbonate, oral, ESRD on Dialysis (Renagel)

J0605    sucroferric oxyhydroxide, oral, ESRD on Dialysis

J0607    lanthanum carbonate, oral, ESRD on Dialysis

J0608    lanthanum carbonate, oral powder, ESRD on Dialysis

J0609    ferric citrate, oral, ESRD on Dialysis

J0615    calcium acetate, oral, ESRD on Dialysis

J0901    vadadustat, oral, ESRD on Dialysis (Vafseo)

 

The following codes have been added to the Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans, and Medicare Authorization Grids and require prior authorization:

C9173   filgrastim-txid (Nypozi)

J0139    adalimumab (Humira)

J0870    imetelstat (Rytelo)

J1307    crovalimab-akkz (Piasky)

J1414    fidanacogene elaparvovec-dzkt (Beqvez)

J1552    immune glob (Alyglo)

J2802    romiplostim (Nplate)

J3392    exagamglogene autotemcel (Casgevy)

J7514    mycophenolate mofetil 100 mg (Myhibbin)

J7601    ensifentrine (Ohtuvayre)

J9026    tarlatamab-dlle (Imdelltra)

J9028    nogapendekin alfa inbakicept-pmln (Anktiva)

J9076    cyclophosphamide (Baxter)

J9292    pemetrexed inj (Avyxa)

Q0155  dronabinol oral (Syndros)

Q0521  Pharmacy supplying fee for HIV pre-exposure prophylaxis fda approved prescription

Q5139  eculizumab-aeeb (Bkemv)

Q5140  adalimumab-fkjp (Hulio)

Q5141  adalimumab-aaty (Yuflyma)

Q5142  adalimumab-ryvk (Simlandi)

Q5143  adalimumab-adbm (Cyltezo)

Q5144  adalimumab-aacf (Idacio)

Q5145  adalimumab-afzb (Abrilada)

Q5146  trastuzumab-strf (Hercessi)

Q9996  ustekinumab SUBQ (Pyzchiva)

Q9997  ustekinumab IV (Pyzchiva)

Q9998  ustekinumab (Selarsdi)

 

Evolent Oncology Program (New Century Health) will require review of the following codes for Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans, and Medicare Products:

C9173   filgrastim-txid (Nypozi)

J0870    imetelstat (Rytelo)

J9026    tarlatamab-dlle (Imdelltra)

J9028    nogapendekin alfa inbakicept-pmln (Anktiva)

J9076    cyclophosphamide (Baxter)

J9292    pemetrexed inj (Avyxa)

Q0155  dronabinol oral (Syndros)

Q5146  trastuzumab-strf (Hercessi)

 

Visit:  Authorization Grids

 

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