Fidelis Care Authorization Grids Effective January 1, 2026 – Pharmacy Updates
10.12.2025
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective January 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:
C9307 linvoseltamab-gcpt inj
C9308 carboplatin (Avyxa) inj
J0013 esketamine, nasal spray
J1073 testosterone pellet, implant
J3387 elivaldogene autotemcel (Skysona)
J3389 prademagene zamikeracel (Zevaskyn)
J7528 mycophenolate mofetil, suspension
J9184 gemcitabine (Avyxa) inj
J9256 nipocalimab-aahu inj
J9282 mitomycin intravesical
J9326 telisotuzumab vedotin-tllv inj (Emrelis)
Q5160 bevacizumab-nwgd (Jobevne)
For Medicaid, CHP, Essential Plan, AmBetter Metal-Level Plans, and Medicare, the following codes have been added to the list of drugs that require NCH review:
C9307 linvoseltamab-gcpt inj
C9308 carboplatin (Avyxa) inj
J9184 gemcitabine (Avyxa) inj
J9282 mitomycin intravesical
J9326 telisotuzumab vedotin-tllv inj (Emrelis)
Q5160 bevacizumab-nwgd (Jobevne)
Visit: Authorization Grids