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Fidelis Care Authorization Grids Effective May 1, 2024
3/29/2024 • Posted by Provider Relations

The following sections of the Fidelis Care authorization grids have been updated effective May 1, 2024.


The following codes have been added on the Medicaid, Medicare, Essential Plan, and Metal-Level Products Authorization Grids and require prior authorization:

C9166   secukinumab

C9167   apadamtase alfa

C9168   mirikizumab-mrkz

J0177    aflibercept hd

J0589    daxibotulinumtoxina-lanm

J1202    miglustat

J1203    cipaglucosidase alfa-atga

J1323    elranatamab-bcmm

J2277    motixafortide

J2782    avacincaptad pegol

J2801    risperidone (Rykindo)

J3055    talquetamab-tgvs

J7165    prothrombin complex concentrate (Balfaxar)

J9073    cyclophosphamide (ingenus)

J9074    cyclophosphamide (sandoz)

J9075    cyclophosphamide, not otherwise specified

J9248    melphalan (hepzato)

J9249    melphalan (apotex)

J9376    pozelimab-bbfg

Q5133  tocilizumab-bavi (tofidence)

Q5134  natalizumab-sztn (tyruko)


The following codes have been added on the Medicare Authorization Grids and require prior authorization:

J0577    buprenorphine extended-release (brixadi), less than or equal to 7 days of therapy 

J0578    buprenorphine extended-release (brixadi), greater than 7 days and up to 28 days of therapy


Evolent Oncology Program (New Century Health) will require review of the following codes for Medicaid, Medicare, Essential Plans and Metal-Level Products:

J0209    sodium thiosulfate (hope)

J1323    elranatamab-bcmm

J1434    fosaprepitant

J2277    motixafortide

J3055    talquetamab-tgvs

J9073    Injection, cyclophosphamide (ingenus)

J9074    Injection, cyclophosphamide (sandoz)

J9075    Injection, cyclophosphamide, not otherwise specified

J9248    Injection, melphalan (hepzato)

J9249    Injection, melphalan (apotex)


Visit:  Authorization Grids



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