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Fidelis Care Authorization Grids Effective April 1, 2019
2/27/2019 • Posted by Provider Relations

The following sections of the Fidelis Care authorization grids have been updated
effective April 1, 2019.

The following services apply to the Medicaid, Child Health Plus, HARP, Essential Plans, and Metal-Level Products (QHP) lines of business, and require prior authorization:

IX.  Pharmacy:
      B.  These injectable codes require prior authorization: 
            J0178 – Eylea  (added)
            J0885 - Procrit/Epogen  (added)
            J2505 – Neulasta  (added)
            J9042 – Adcetris  (added)
            J9271 – Keytruda  (added)
            J9299 – Opdivo  (added)

The following services apply to Medicare Advantage and Dual Advantage, and require prior authorization:

VIII.  Pharmacy:
      B.  These injectable codes require prior authorization: 
            J9310 (deleted)
            J9311 and J9312 (added) to replace discontinued code J9310

Visit:  Authorization Grids

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