Fidelis Care Authorization Grids Effective October 1, 2021 ...

Non-Therapy Providers (MD, DO, DPM, etc.) should request prior authorization for all services after the initial evaluation directly through Fidelis Care. The following services apply to Medicaid, Essential Plan, & Metal Level Plans and require prior authorization: VIII. Pharmacy. Added: J1943 aripiprazole lauroxil, (Aristada Initio.

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