11/29/2023
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective January 1, 2024.
The following codes have been added to the Medicare, Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and requires prior authorization:
V. Outpatient and DME Services: The following services require prior authorization:
5. Other services: 96547, 96548, 97037
The following codes have been removed from the Medicaid DME Authorization Grid and do not require prior authorization effective December 1, 2023:
K1036 Supplies for ultra diathermy
L1681 Ho bilateral hip abduction
L5991 Low pros ext osseo connector
The following codes have been updated on the Medicare, Medicaid, Essential Plan, and Metal-Level Products Authorization Grid and requires prior authorization:
C9159 prothrombin complex concentrate (human) (Balfaxar)
C9160 daxibotulinumtoxina-lanm
C9161 aflibercept hd
C9162 avacincaptad pegol
C9163 talquetamab-tgvs
C9164 cantharidin topical
C9165 elranatamab-bcmm
J0217 velmanase alfa-tycv
J0402 aripiprazole (Abilify asimtufii)
J0750 emtricitabine-tenofovir df, oral for PReP
J0751 emtricitabine-tenofovir alafenamide, oral for PReP
J0799 unclassified FDA approved PReP drugs
J1246 dinutuximab (Unituxin)
J1304 tofersen (Qalsody)
J1412 valoctocogene roxaparvovec-rvox (Rocavian)
J1413 delandistrogene moxeparvovec-rokl (Elevidys)
J2508 pegunigalsidase alfa-iwxj
J2799 risperidone (Uzedy)
J3401 beremagene geperpavec-svdt (Vyjuvek)
J9052 carmustine (Accord)
J9072 cyclophosphamide, (Dr. Reddy’s)
J9172 docetaxel (Ingenus)
J9255 methotrexate (Accord)
J9258 paclitaxel protein-bound particles (Teva)
J9286 glofitamab-gxbm (Columvi)
J9321 epcoritamab-bysp (Epkinly)
J9324 pemetrexed (Pemrydi RTU)
J9333 rozanolixizumab-noli (Rystiggo)
J9334 efgartigimod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)
Q0516 Pharmacy supplying fee for HIV pre-exposure prophylaxis fda approved prescription drug, per 30-days
Q0517 Pharmacy supplying fee for HIV pre-exposure prophylaxis fda approved prescription drug, per 60-days
Q0518 Pharmacy supplying fee for HIV pre-exposure prophylaxis fda approved prescription drug, per 90-days
Q5132 adalimumab-afzb (Abrilada)
Visit: Authorization Grids