The following section of the Fidelis Care authorization grids has been updated effective July 1, 2026.
The following codes have been updated on the Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans, and Medicare Authorization Grids and require prior authorization:
C9310 leucovorin calcium (avyxa), inj
J1289 narsoplimab-wuug, inj (Yartemlea)
J1577 immune globulin, inj (Qivigy)
J2361 depemokimab-ulaa, inj (Exdensur)
J2789 riboflavin 5'-phosphate, ophthalmic (Epioxahd/Epioxa)
J3386 etuvetidigene autotemcel, inj (Waskyra)
J3405 onasemnogene abeparvovec-brve, inj (Itvisma)
J9053 belantamab mafodotin-blmf, inj (Blenrep)
J9062 amivantamab and hyaluronidase-lpuj, inj (Rybrevant)
J9232 docetaxel (hospira), inj
Q5164 ustekinumab-hmny, inj (Starjemza)
Q5165 denosumab-mobz, inj (Oziltus)
Q5166 denosumab-desu, inj (Osvyrti/Jubereq)
Q5167 denosumab-qbde, inj (Enoby/Xtrenbo)
Q5168 ranibizumab-leyk, inj (Nufymco)
Q5169 pegfilgrastim-unne, inj (Amlupeg)
Q5170 aflibercept-boav, inj (Eydenzelt)
Q5171 denosumab-mobz, inj (Boncresa)
For Medicaid, Essential Plan, Ambetter Metal-Level Plans, and Medicare, the following codes have been added to the list of drugs that require NCH review:
C9310 leucovorin calcium (avyxa), inj
J9053 belantamab mafodotin-blmf, inj (Blenrep)
J9062 amivantamab and hyaluronidase-lpuj, inj (Rybrevant)
J9232 docetaxel (hospira), inj
Q5165 denosumab-mobz, inj (Oziltus)
Q5166 denosumab-desu, inj (Osvyrti/Jubereq)
Q5167 denosumab-qbde, inj (Enoby/Xtrenbo)
Q5169 pegfilgrastim-unne, inj (Amlupeg)
Q5171 denosumab-mobz, inj (Boncresa)
The following codes have been added to the TurningPoint authorization grid and require prior authorization:
33203 Insertion of epicardial electrode(s); endoscopic approach (eg, thoracoscopy, pericardioscopy)
33210 Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure)
33211 Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate procedure)
0913T Percutaneous transcatheter therapeutic drug delivery by intracoronary drug-delivery balloon (eg, drug-coated, drug-eluting), including mechanical dilation by nondrug-delivery balloon angioplasty, endoluminal imaging using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) when performed, imaging supervision, interpretation, and report, single major coronary artery or branch
Visit: Authorization Grids