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Fidelis Care Authorization Grids Effective March 1, 2025
29.01.2025 • Posted by Provider Relations

The following codes have been removed from the Medicaid and  Essential Plan Authorization Grids and do not require prior authorization:

J0739 cabotegravir inj 

J0741 cabotegrvir and rilpivirine inj 

J0750 emtricitabine tenofovir df, oral for PReP 

J0751 emtricitabine tenofovir alafenamide, oral for PReP 

J0799 unclassified FDA approved PReP drugs 

J1746 ibalizumab-uiyk (Trogarzo) 

J1961 lenacapavir (Sunlenca) 

Q0521 Pharmacy supplying fee for HIV pre-exposure prophylaxis FDA approved prescription

S0104 zidovudine oral 

S0140 saquinavir oral 

 

Visit:  Authorization Grids

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