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Fidelis Care Authorization Grids Effective June 1, 2021
4/30/2021 • Posted by Provider Relations

The following sections of the Fidelis Care authorization grids have been updated effective June 1, 2021.

 

The following services apply to Medicaid, Essential Plan, and Metal Level Plans and require prior authorization:

 

VIII. Pharmacy

Added:

S0012    butorphanol nasal

S0017    aminocaproic acid inj

S0020    bupivicaine inj

S0021    cefoperazone inj

S0034    ofloxacin inj

S0040    ticarcillin inj

S0074    cefotetan inj

S0078    fosphenytoin inj

S0080    pentamidine inj

S0081    piperacillin inj

S0088    imatinib oral

S0090    sildenafil oral

S0091    granisetron oral

S0104    zidovudine oral

S0106    bupropion SR, 60 tablets

S0108    mercaptopurine oral

S0109    methadone oral

S0117    tretinoin topical

S0119    ondansetron oral

S0132    ganirelix acetate inj

S0137    didanosine oral

S0138    finasteride oral

S0139    minoxidil oral

S0140    saquinavir oral

S0142    colistimethate inh

S0145    peg interferon alfa-2A

S0148    pegylated interferon alfa-2B

S0155    dilutant for epoprostenol

S0156    exemestane oral

S0157    becaplermin gel

S0160    dextroamphetamine oral

S0164    pantoprazole inj

S0169    calcitriol oral

S0170    anastrozole oral

S0172    chlorambucil oral

S0174    dolasetron oral

S0175    flutamide oral

S0176    hydroxyurea oral

S0177    levamisole oral

S0179    megestrol oral

S0182    procarbazine oral

S0183    prochlorperazine oral

S0187    tamoxifen citrate oral

S0190    mifepristone, oral 200 mg

S0191    misoprotol, oral, 200 mcg

S0194    vitamin suppl 100 caps

S0197    prenatal vitamins – 30 days

S4989    contraceptive IUD including implants and supplies

S4990    nicotine patches, legend

S4991    nicotine patches, non-legend

S4993    contraceptive oral

S4995    smoking cessation gum

S5000    prescription drug, generic

S5001    prescription drug, brand name

S9430    pharmacy compounding and  dispensing services

 

The following services apply to Medicare Plans:

VIII. Pharmacy

Added (Medicare) – Requiring Authorization:

J0791     crizanlizumab (Adakveo)

J1429     golodirsen (Vyondys 53)

J1442     filgrastim (Neupogen)

J1447     tbo-filgrastim (Granix)

J2505     pegfilgrastim (Neulasta)

J2507     pegloticase (Krystexxa)

J2820     Sargramostim (Leukine)

J7312     dexamethasone intravitreal implant (Ozurdex)

J9177     Enfortumab vedotin-ejfv (Padcev)

J9355     trastuzumab (Herceptin)

J9356     trastuzumab hyal (Herceptin Hylecta)

Q5108   pegfilgrastim-jmdb (Fulphila)

Q5110   filgrastim-aafi (Nivestym)

Q5111   pegfilgrastim-cbqv (Udenyca)

Q5112   trastuzumab-dttb (Ontruzant)

Q5113   trastuzumab-pkrb (Herzuma)

Q5117   trastuzumab-anns (Kanjinti)

Q5122   pegfilgrastim-apg (Nyvepria)

 

Removed (Medicare):

C9061    teprotumumab-trbw, 10 mg (Tepezza)

C9062    daratumumab and hyaluronidase-fihj (Darzalex Faspro)

C9069    belantamab mafodontin-blmf (Blenrep)

C9070    tafasitamab-cxix (Monjuvi)

C9071    viltolarsen (Viltepso)

C9072    immune globulin (asceniv)

C9073    Brexucabtagene autoleucel (Tecartus)

C9122    Mometasone furoate sinus implant, 10 micrograms (Sinuva)

J2353     ocreotide (Sandostatin Depot)

J2354     ocreotide (Sandostatin subcutaneous)

J1930     lancreotide (somatuline depot)

 

Conditions Updated (Medicare):

J9035**  bevacizumab (Avastin)  Updated **authorization is not required for ophthalmic indications

 

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.

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