Update Fidelis Care Authorization Grids Effective October 1, 2019
9/27/2019
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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).
Authorization Grids