Additional Updates to Fidelis Care Authorization Grids Effective July 1, 2023
15.06.2023
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective July 1, 2023.
The following codes have been updated on the Medicare, Medicaid, Essential Plan, and Metal-Level Plan Authorization Grids and require prior authorization:
C9151 pegcetacoplan (Empaveli)
J1440 fecal microbiota (Rebyota)
J1576 immune globulin intravenous, human – ifas
J1961 lenacapavir (Sunlenca)
*J2427 paliperidone palmitate ER (Invega Hafyera or Invega Trinza)
J7213 coagulation factor IX recombinant (Ixinity)
J9029 nadofaragene firadenovec-vncg (Adstiladrin)
J9056 bendamustine
J9058 bendamustine
J9059 bendamustine
J9063 mirvetuximab soravtansine-gynx (Elahere)
J9259 paclitaxel
J9322 pemetrexed
J9323 pemetrexed ditromethamin
J9347 tremelimumab-actl (Imjudo)
J9350 mosunetuzumab-axgb (Lunsumio)
J9380 teclistamab cqy (Tecvayli)
J9381 teplizumab mzwv (Tzield)
Q5131 adalimumab-aac (Idacio)
*This code applies to Medicaid, Essential Plans, and Metal-Level Plans
New Century Health (NCH) will require review of the following codes as of July 1, 2023 for Medicare, Medicaid, Essential Plans and Metal-Level products:
J9029 nadofaragene firadenovec-vncg (Adstiladrin)
J9056 bendamustine injection (Vivimusta)
J9058 bendamustine HCL injection (Apotex)
J9059 bendamustine HCL injection (Baxter)
J9063 mirvetuximab soravtansine-gynx (Elahere)
J9259 paclitaxel proteinbound particles (Abraxane)
J9322 pemetrexed injection (Bluepoint)
J9323 pemetrexed injection
J9347 tremelimumab-actl injection (Imjudo)
J9350 mosunetuzumab-axgb injection (Lunsumio)
J3890 teclistamab-cqyv injection (Tecvayli)
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