5/29/2025
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Posted by Provider Relations
The following section of the Fidelis Care authorization grids have been updated effective July 1, 2025.
The following DME codes have been removed from the Medicaid, Essential Plan, and Ambetter Metal-Level Products Authorization Grids and no longer require prior authorization:
K0001 Standard wheelchair
L0621 SIO flex pelvisacral prefab
L2630 Pelvic control band and belt B
L3809 Whfo w/o joints pre ots
The following code has been updated on the Medicaid, Essential Plan, and Ambetter Metal-Level Plans Authorization Grids and requires prior authorization:
Q0224 pemivibart (Pemgarda)
The following codes have been updated on the Medicare, Medicaid, Essential Plan, and Ambetter Metal-Level Plans Authorization Grids and require prior authorization:
C9174 datopotamab deruxtecan-dlnk (Datroway)
C9175 treosulfan (Grafapex)
J1326 zolbetuximab-clzb (Vyloy)
J3391 atidarsagene autotemcel (Lenmeldy)
J7172 marstacim-hncq (Hympavzi)
J7356 foscarb/foslevodopa (Vyalev)
J9174 docetaxel (Beizray)
J9275 cosibelimab-ipdl (Unloxcyt)
J9276 aznidatamab-hrii (Ziihera)
J9289 nivolumab and hyaluronidase-nvhy (Opdivo Qvantig)
J9341 thiotepa (tepylute)
J9342 thiotepa nos
J9382 zenocutuzumab-zbco (Bizengri)
Q2058 obecabtagene autoleucel (Aucatzyl)
Q5098 ustekinumab-srlf (Imuldosa)
Q5099 ustekinumab-stba (Steqeyma)
Q5100 ustekinumab-kfce (Yesintek)
Q5153 aflibercept-yszy (Opuviz)
The following codes have been added to the list of drugs that require NCH review on the Medicare, Medicaid, Essential Plan and Ambetter Metal-Level Plans Authorization Grids:
C9174 datopotamab deruxtecan-dlnk (Datroway)
C9175 treosulfan (Grafapex)
J1326 zolbetuximab-clzb (Vyloy)
J9174 docetaxel (Beizray)
J9275 cosibelimab-ipdl (Unloxcyt)
J9276 aznidatamab-hrii (Ziihera)
J9289 nivolumab and hyaluronidase-nvhy (Opdivo Qvantig)
J9341 thiotepa (tepylute)
J9342 thiotepa nos
J9382 zenocutuzumab-zbco (Bizengri)
Visit: Authorization Grids