2025/4/28
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Posted by Provider Relations
The following section of the Fidelis Care authorization grids have been updated effective June 1, 2025.
The following codes have been updated on the Medicaid, Essential Plan, and Ambetter Metal-Level Products Authorization Grids and require prior authorization:
B. Durable Medical Equipment/Supplies:
T2101 (Donor Breast Milk) only requires an authorization when given in an outpatient setting.
The following codes have been updated on the Essential Plan and Ambetter Metal-Level Products Authorization Grids and require prior authorization:
III. Outpatient surgery: The following services require prior authorization:
D. Skin surgery and other dermatological procedures: A2025
The following codes have been updated on the Medicaid, Essential Plan, and Ambetter Metal-Level Plans Authorization Grids and require prior authorization:
J7503 tacrolimus, ER (Envarsus XR)
J7507 tacrolimus, immediate release
J7508 tacrolimus, ER (Astagraf XL)
J7521 tacrolimus granules
The following codes have been updated on the Essential Plan and Ambetter Metal-Level Plans Authorization Grids and require prior authorization:
J0485 belatacept inj (Nulojix)
Visit: Authorization Grids