Fidelis Care Prior Authorization Lookup
Latest Fidelis Care prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Authorization Grid Detail, Effective June 1, 2026Part 2 of Fidelis Care Authorization Grid Detail describes services that require prior authorization or are exempt (imaging, DXA/TBS, therapy authorizations, podiatry, therapeutic services, long-term home health, ADHC, certain DME/ED items, counseling limits, outside vendor prior auths) and provides Appendix I: extensive list of HCPCS/J-codes requiring prior authorization.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Oncology Services - Medicare | Oncology medication prior authorization and billing list (Wellcare by Fidelis Care)Defines Evolent review/prior authorization requirements and lists HCPCS/HCPCS-like and pharmacy codes for oncology medications and supportive agents for Wellcare by Fidelis Care Medicare members; includes out-of-scope items and preferred biosimilar agents. Applies to dispensing at pharmacy or administration in physician office, outpatient hospital, or ambulatory settings.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Oncology medications and supportive agents prior authorizationRequirements for Evolent review/prior authorization of oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care members; applies to participating providers dispensing/administering these drugs via pharmacy or medical settings.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Oncology medications and supportive agents prior authorization (Medicare - Wellcare by Fidelis Care)Defines prior authorization and review requirements by Evolent for oncology medications and supportive agents (medical and pharmacy benefit) for Fidelis Care Medicare - Wellcare participating providers; lists drugs/HCPCS/J-codes requiring review and out-of-scope items.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Authorization Grid Detail, Effective March 1, 2026Defines prior authorization, notification, and utilization review requirements across inpatient, outpatient, behavioral health, DME, home health, imaging, and other services for Fidelis Care Medicaid, Child Health Plus (CHP) and HealthierLife plans (partial document — Part 1 of 3). Includes delegated reviewers and special program-specific rules.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Oncology medications and supportive agents prior authorization (Wellcare by Fidelis Care)Requires review by Evolent for oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care members prior to dispensing or administration across pharmacy, physician office, outpatient hospital, or ambulatory settings; applies to participating providers (non-participating submission instructions also provided).All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Oncology medications and supportive agents prior authorization (Wellcare by Fidelis Care)This policy governs prior authorization and review requirements for oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care members, describing which drugs require review by Evolent and what providers must submit. It affects participating providers dispensing or administering oncology regimens in pharmacy, physician office, outpatient hospital, or ambulatory settings.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Oncology medications and supportive agents prior authorization and reviewGoverns requirement for Evolent review/prior authorization of oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care members; affects participating providers dispensing or administering listed drugs in pharmacy, physician office, outpatient hospital, or ambulatory settings.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-11-01Oncology medications and supportive agents prior authorization (Wellcare by Fidelis Care)Requires review by Evolent for oncology medications and supportive agents (medical or pharmacy benefit) for participating providers prior to dispensing or administration for members; includes list of HCPCS/J-codes and oral oncology drugs that require review. Applies to Medicare - Wellcare by Fidelis Care members.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-01Formulary alternative drugs and restrictionsThis document lists commonly used brand drugs that are not covered by the WellCare by Fidelis Care formulary and the covered alternative drugs, including any formulary restrictions (e.g., prior authorization, quantity limits). It is intended for providers and pharmacists and applies to the plan's pharmacy benefit.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-01Prior Authorization and Coverage Criteria — Fidelis Care Medicaid/CHP/HealthierLifeOperational and authorization guidance for Fidelis Care Medicaid/CHP/HealthierLife providers covering inpatient, outpatient, behavioral health, transplant, surgical, and substance use disorder services in New York State. Affects network and non-network providers rendering services to Fidelis Care members.All Fidelis Care updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-09-01Managed Long Term Care (MLTC) eligibility and billing for Fidelis Care FCAH and MAPGovernance of eligibility requirements, covered services, prior authorization and claims/billing rules for Fidelis Care Homecare (FCAH) and Medicaid Advantage Plus (MAP) MLTC members in New York State; affects providers delivering home- and community-based long‑term care services to Fidelis MLTC/MAP members.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-09-01Oncology medications and supportive agents prior authorizationThis policy governs prior review/authorization requirements for oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care members and specifies agent lists, biosimilar preferences, and submission instructions for participating and non-participating providers.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-07-01Oncology medications and supportive agents prior authorization (Wellcare by Fidelis Care)Governs prior review/authorization requirements for oncology medications and supportive agents for Wellcare by Fidelis Care (Medicare) members; affects participating providers dispensing or administering these drugs in pharmacy, physician office, outpatient hospital, or ambulatory settings.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-06-01Oncology medications and supportive agents prior authorization and reviewDefines Evolent review and prior authorization requirements for oncology medications and supportive agents for Wellcare by Fidelis Care Medicare members; applies to participating providers dispensing/administering drugs in pharmacy, physician office, outpatient hospital, or ambulatory settings.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-05-01Authorization and Utilization Review — Facility, Post-Acute, Behavioral Health, and Select Outpatient ServicesGoverns prior authorization, utilization review, and service-specific authorization rules for Fidelis Care Medicaid (and related lines) providers in New York State, including inpatient, outpatient, behavioral health, SUD, transplant, and surgical services.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-05-01Oncology medications and supportive agents prior authorization (Evolent review)Requires review by Evolent for oncology medications and supportive agents (medical or pharmacy benefit) before dispensing or administration for Wellcare by Fidelis Care Medicare members; applies to participating providers with submission instructions for non‑participating providers.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-02-01Oncology medications and supportive agents prior authorizationRequires review by Evolent for oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care participating providers before dispensing or administration in outpatient/ambulatory settings; lists HCPCS/CPT codes and preferred biosimilars. Affects providers submitting oncology regimens for members in North Carolina.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-01Prior Authorization and Coverage Criteria — Actemra (tocilizumab) subcutaneous and Tyenne productsThis policy governs prior authorization and coverage criteria for Actemra (subcutaneous and ACTPen) and Tyenne (autoinjector and subcutaneous) products for Fidelis Care members in North Carolina; it affects prescribers, pharmacists, and prior authorization reviewers.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-01Prior Authorization and Coverage Criteria — Inpatient, Outpatient and Behavioral Health ServicesGoverns Fidelis Care authorization requirements for inpatient admissions, selected outpatient surgeries, and behavioral health services (including carve-ins and specific services requiring authorization) for providers and facilities in New York State network.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-01Tocilizumab (Actemra/Tyenne) prior authorization and coverage criteriaDefines prior authorization, clinical criteria, prescriber and age restrictions, and continuation requirements for Actemra/Tyenne subcutaneous products for Fidelis Care members in North Carolina.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2024-12-01Oncology medications and supportive agents prior authorization (Evolent/NCH review)This policy requires review by Evolent (formerly New Century Health / NCH) for oncology medications and supportive agents (medical or pharmacy benefit) before dispensing or administration for Medicare - Wellcare by Fidelis Care members; it applies to participating providers and describes submission channels and scope/exclusions.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2024-08-01Oncology medications and supportive agents prior authorization and reviewThis policy governs prior review/authorization requirements for oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care members, specifying drugs and HCPCS/J-codes that require review by Evolent/New Century Health and which requests are out of scope. It applies to participating providers and describes submission channels.All Fidelis Care updates
- Prior AuthClinical/Medical PolicyEff. 2024-07-01Oncology medications and supportive agents prior authorization and reviewDefines which oncology medications and supportive agents require review by Evolent/New Century Health (NCH) for Fidelis Care (Wellcare) Medicare members, and lists HCPCS/J-codes and pharmacy agents in scope and out-of-scope items. Affects participating providers dispensing or administering oncology drugs in outpatient, office, or pharmacy settings.All Fidelis Care updates
- Prior AuthAdministrative/Operational PolicyEff. 2024-06-01Medication request / prior authorization formAll Fidelis Care updates
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Tool Description
Search Fidelis Careprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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