CurrentFidelis CarePolicy N/A

Oncology Services - Essential Plan and Metal-Level Products/QHP

Defines prior authorization and review requirements by Evolent for oncology medications and supportive agents dispensed or administered for members in Essential Plan and Qualified Health Plans (pharmacy, physician office, outpatient hospital, ambulatory settings). Lists out-of-scope items and enumerates HCPCS/J-codes and other drug codes requiring prior authorization; requires submission of entire oncology regimen.

Policy Summary

PayerFidelis Care

PolicyOncology Services - Essential Plan and Metal-Level Products/QHP

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must submit oncology medication and supportive agent requests (entire regimen) to Evolent for review prior to dispensing or administration via my.newcenturyhealth.com or by phone at 1-888-999-7713, option 1.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this brief.

200+Enumerated Codes Requiring Review

1Prior Authorization Vendor

2022-07-01Pediatric & trials inclusion date

Coverage Summary

Payer: Essential Plan and Qualified Health Plans — Policy: Oncology medications and supportive agents prior authorization (delegated to Evolent). Defines prior authorization and review requirements by Evolent for oncology medications and supportive agents dispensed or administered in pharmacy, physician office, outpatient hospital, or ambulatory settings. Key stats: Enumerated Codes Requiring Review: 200+; Prior Authorization Vendor: 1 (Evolent); Pediatric membership & clinical trials inclusion date: 2022-07-01.

Key facts

ScopePrior authorization and review by Evolent for oncology medications and supportive agents for members in Essential Plan and Qualified Health Plans (dispensed at pharmacy or administered in physician office, outpatient hospital, ambulatory settings).

Coverage stanceCovered with criteria — prior authorization required for listed HCPCS/J-/other drug codes; many specific codes enumerated in policy.

StatusCURRENT

Effective date / Policy numberEffective date: N/A; Policy number: N/A

Pediatric & clinical trials inclusion datePediatric members and clinical trials may be included/submitted for review beginning 2022-07-01.

Medical-Necessity / Prior Authorization Criteria

General Prior Authorization Requirement

Oncology medications and supportive agents require review by Evolent before dispensing or administration:

ALL of the following

Applies to members covered under Essential Plan and Qualified Health Plans (members 18 and older; pediatric membership to be included starting 2022-07-01).
Submission methods: Requests must be submitted to Evolent via web portal (my.newcenturyhealth.com) or by phone (1-888-999-7713, option 1).
Submit entire regimen: Submit the entire oncology regimen to Evolent regardless of prior authorization requirement; omissions may result in denial.
Clinical trials may be sent to Evolent for review effective 2022-07-01.

Out-of-Scope (Do Not Submit to Evolent)

The following requests are out of scope and should not be submitted to Evolent:

Out-of-scope requests

Antibiotics
Bone marrow / transplants / CAR-T: Bone Marrow, Stem Cell Transplants, CAR-T Cell Therapy
Cablivi
Controlled substances: Controlled Substances
Equipment requests: Equipment Requests (infusion pumps)

Prior Authorization by HCPCS/Drug Codes

The following HCPCS/CPT/J-codes and miscellaneous codes require prior authorization (listed as provided).

HCPCS/J-code list: Extensive enumerated list of HCPCS/J-codes and miscellaneous drug codes (see code_groups for full listing)

Refer to policy for full enumerated code list

Codes Requiring Prior Authorization

Required prior authorization - HCPCS / J-codes / other drug codes (enumerated list from policy body)mixedCovered

C9293	GLUCARPIDASE
J1246
J0185	DINUTUXIMAB / APREPITANT INJECTION / SUTIMLIMAB-JOME INJECTION (listed variants)
J0207	AMIFOSTINE 500 MG INJ / J1323 ELRANATAMAB-BCMM
J0208	SODIUM THIOSULFATE / J1326 / ZOLBETUXIMAB-CLZB (VYLOY)
J0594	BUSULFAN 1 MG INJ / J1434 / FOSAPREPITANT (FOCINVEZ)
J0641	LEVOLEUCOVORIN CALCIUM INJECTION / J1442 / FILGRASTIM G-CSF 1 MCG INJECTION
J0642	LEVOLEUCOVORIN / J1447 / TBO-FILGRASTIM
J0870	IMETELSTAT (RYTELO) / J1448 / TRILACICLIB INJECTION
J0881	INJECTION DARBEPOETIN ALFA 1 MCG NON-ESRD / J1449 / J1453 / EFLAPEGRASTIM-XNST (ROLVEDON)

1–10 of 178

1/18

Provider Actions & Requirements

Prior Authorization

Submit oncology medication requests to Evolent

Providers must submit oncology medication and supportive agent requests (entire regimen) to Evolent for review prior to dispensing or administration via my.newcenturyhealth.com or by phone at 1-888-999-7713, option 1.

Web portal: my.newcenturyhealth.com
Phone: 1-888-999-7713, option 1

Documentation Required

Include entire oncology regimen

Failure to submit the entire oncology regimen may result in a denial; include all agents even if individual agents may not require prior authorization.

Omission of any regimen agent may result in denial — include all agents even if some may not individually require prior authorization.

Prior Authorization

Clinical trials review

Clinical trial requests may be submitted to Evolent for review.

Effective date: 2022-07-01

Background

Policy delegates prior authorization review of oncology medications and supportive agents to Evolent for members covered under Essential Plan and Qualified Health Plans. Requests must be submitted to Evolent via the web portal (my.newcenturyhealth.com) or by phone (1-888-999-7713, option 1). Pediatric members are to be included beginning July 1, 2022, and clinical trials may be submitted for review effective that same date. The policy emphasizes that providers must submit the entire oncology regimen to Evolent regardless of individual agent prior authorization status; omissions may result in denial.