3/29/2024
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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