7/1/2020
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Posted by Provider Relations
COVID-19 UPDATE:
Please refer to this link: Important Updates Regarding Coronavirus COVID-19, for authorization and coding guidelines related to the COVID-19 Pandemic.
The following sections of the Fidelis Care authorization grids have been updated effective August 1, 2020.
Prior Authorization for Gender Reassignment Surgery: 55970, 55980 has been removed from all lines of business:
III. Outpatient surgery: The following services require prior authorization:
L. Gender Reassignment Surgery: 55970, 55980 [removed]
Prior Authorization has been added for the lines of business as indicated:
IX. Pharmacy:
C. Applies to Essential Plan, Medicaid, and Metal-Level Products (Qualified Health Plans):
Added:
J0207 amifostine (Ethyol)
J0641 levoleucovorin
J1447 tbo-filgrastim (Granix)
J2425 palifermin (Kepivance)
J2783 rasburicase (Elitek)
J3315 triptorelin pamoate (Trelstar)
J9015 aldesleukin (Proleukin)
J9035 bevacizumab (Avastin)**
J9039 blinatumomab (Blincyto)
J9044 bortezomib (Velcade)
J9047 carfilzomib (Kyprolis)
J9120 dactinomycin (Cosmegan)
J9145 daratumumab (Darzalex)
J9176 elotuzumab (Empliciti)
J9205 irinotecan liposome (Onivyde)
J9245 melphalan hydrochloride (Melphalan)
J9261 nelarabine (Arranon)
J9285 olaratumab (Lartruvo)
J9301 obinutuzumab (Gazyva)
J9307 pralatrexate (Folotyn)
J9325 talimogene laherparepvec (Imlygic)
J9328 temozolomide (Temodar)
J9330 temsirolimus (Torisel)
J9352 trabectedin (Yondelis)
J9355 trastuzumab (Herceptin)
J9356 trastuzumab hyal (Herceptin Hylecta)
Q2043 sipuleucel-T (Provenge)
Q5110 filgrastim-aafi (Nivestym)
Q5112 trastuzumab-dttb (Ontruzant)
Q5113 trastuzumab-pkrb (Herzuma)
Q5115 rituximab-abbs (Truxima)
Q5117 trastuzumab-anns (Kanjinti)
S0178 lomustine (Gleosine)
**authorization is not required for ophthalmic indications
Visit: Authorization Grids