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Fidelis Care Authorization Grids Effective March 1, 2025
1/29/2025 • Posted by Provider Relations

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 

 

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