3/1/2021
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective April 1, 2021.
The following services apply to Medicaid, Essential Plan, and Metal Level Plans and require prior authorization:
VIII. Pharmacy
Added:
J2760 phentolamine inj
*3/13/2021 Update*: The following services apply to Medicaid, Medicare, Essential Plan, and Metal Level Plans and require prior authorization:
VIII. Pharmacy
Added
C9074 lumasiran (Oxlumo)
J1427 viltolarsen (Viltepso)
J1554 immune glob (Asceniv)
J7402 Mometasone furoate sinus implant (Sinuva)
J9037 belantamab mafodotin (Blenrep)
J9349 Tafasitamab (Monjuvi)
Q2053 Brexucabtagene autoleucel (Tecartus)
Removed from Medicaid, Essential Plan, and Metal Level Plans only:
C9122 Mometasone furoate sinus implant (Sinuva)
J7333 hyaluronan
J7401 Mometasone furoate sinus implant (Sinuva)
Visit: Authorization Grids
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.