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Update Fidelis Care Authorization Grids Effective October 1, 2019
9/27/2019 • Posted by Provider Relations

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

The following services apply to Essential Plan, Medicaid, Child Health Plus, HealthierLife (HARP), Medicare, and Metal-level Products and require prior authorization:

VIII. or IX.  Pharmacy:  
           B.  These codes requires authorization: (with the exception of B4088):

Added:   J0222    patisiran (Onpattro)
                 J0593    lanadelumab-flyo (Takhzyro)
                 J1096    dexamethasone ophthalmic insert (Dextenza) 
                 J1303    ravulizumab (Ultomiris)
                 J3031    fremanezumab-vfrm (Ajovy)
                 J3111    romosozumab (Evenity)
                 J7311    fluocinolone acetonide, intravitreal implant (Retisert)
                 J7313    fluocinolone acetonide, intravitreal implant (Iluvien)
                 J7314    fluocinolone acetonide, intravitreal implant (Yutiq)
                 J7331    hyaluronan (Synojoynt)
                 J7332    hyaluronan (Triluron) 
                 J7401    Mometasone furoate sinus implant (Sinuva)
                 J9118    calaspargase pegol-mknl (Asparlas)
                 J9119    cemiplimab-rwlc (Libtayo)
                 J9204    mogamulizumab-kpkc (Poteligeo)
                 J9210    emapalumab (Gamifant)
                 J9269    tagraxofusp (Elzonris)
                 J9313    moxetumomab pasudotox-tdfk (Lumoxiti)

Removed:    C9051 omadacycline (Nuzyra)

Medicaid only:  

J7331, J7332 (added codes) …are non-covered when billed with CPT code 20610 or 20611 or any of the following diagnosis: M17.0, M17.10-M17.12, M17.2, M17.20-M17.32, M17.4, M17.5, M17.

Medicare only:

IV.  Outpatient and DME Services:  these services require prior authorization:
       H.  Therapeutic Services:
              4.  Pain Management – Clarified that this applies to: (for non-orthopedists only).

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Each day, Fidelis Care's Utilization Management (UM) Department makes decisions on many health insurance claims. These decisions are based only on appropriateness of care and the existence of coverage. 

Fidelis Care does not reward providers or other individuals for issuing denials of coverage, and does not offer financial incentives to UM staff based on decisions that promote underutilization of services. 

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