Fidelis Care Authorization Grids Effective September 1, 2019
The following sections of the Fidelis Care authorization grids have been updated
effective September 1, 2019.
The following services apply to all lines of business and require or exclude prior authorization as noted:
IV. or V. Outpatient and DME Services:
2. Note: Authorization is not required for CPT 81220, 81329 and 81336.
CPT 81220 has a lifetime limit of 1. CPT 81329 and 81336 have a
combined limit of 1 per lifetime.
IX. Pharmacy: (no changes to the Medicare grid)
B. This code requires authorization:
Q3028 interferon beta-1a, SC (Rebif) (added)
Note: The pharmacy code description has been added to each code.
Visit: Authorization Grids