2/1/2022
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective March 1, 2022.
The Medicaid, Medicare, Essential Plan, & Metal Level Plan grids have been updated as follows:
Pharmacy:
- These codes require authorization under Medicare Plans.
J0881 darbepoetin alfa, non-ESRD use (Aranesp)
J0882 darbepoetin alfa, ESRD use (Aranesp)
J0885 epoetin alfa, non-ESRD use (Epogen, Procrit)
J2186 meropenem, vaborbactam (Vabomere)
J9271 Pembrolizumab (Keytruda)
J9299 nivolumab (Opdivo)
J9309 polatuzumab vedotin-piiq (Polivy)
J9354 ado-trastuzumab emtansine (Kadcyla )
J9999 Not otherwise classified, antineoplastic drugs -Miscellaneous chemotherapy
Q4081 epoetin alfa, ESRD use (Epogen, Procrit)
- The following codes have been removed from the Medicaid, Essential Plan, & Metal Level Plan authorization grids:
J0885 epoetin alpha, non-ESRD (Epogen, Procrit)
Q4081 epoetin alfa ESRD (Epogen, Procrit)
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.