CurrentFidelis CarePolicy N/A

Oncology medication prior authorization and HCPCS/J-codes list

Defines prior review/authorization requirements for oncology medications and supportive agents for Fidelis Care Medicaid Managed Care & HealthierLife members and lists HCPCS/J/Q/C/G codes that require authorization or are in-scope for review.

Policy Summary

PayerFidelis Care

PolicyOncology medication prior authorization and HCPCS/J-codes list

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to New Century Health (Evolent) via their web portal or phone prior to dispensing or administration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14document chunks

hundredsHCPCS/J/Q codes listed

18+member age threshold

Out-of-scope listexplicit exclusions

Coverage and Prior Review Criteria

Prior Review Criteria

Covered when ALL of the following are met

Prior review requirement: Medication is an oncology medication or supportive agent to be dispensed at a pharmacy or administered in an outpatient setting (physician office, outpatient hospital, or ambulatory setting)

Applies to members age 18 and older; pediatric membership included starting 7/1/2022

Submission requirement: Provider submits the entire oncology regimen to New Century Health (Evolent) via their web portal or phone prior to dispensing or administration

Omissions may result in denial

The following items are explicitly out of scope for submission to New Century Health (Evolent) and should NOT be submitted for prior review: Antibiotics; Bone marrow/stem cell transplants; CAR-T cell therapy; Cablivi; Controlled substances; Equipment requests (infusion pumps); Genetic lab testing and laboratory services; Hemophilia drugs; Immune globulins; Inpatient drug requests; Iron preparations; Pain medications; Radiopharmaceuticals; Surgeries/surgical procedures; and Sickle cell diagnoses.

Policy Summary

PayerFidelis Care

PolicyOncology medication prior authorization and HCPCS/J-codes list

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to New Century Health (Evolent) via their web portal or phone prior to dispensing or administration.

SourceLink

On This Page

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HCPCS / J / Q Codes Requiring Review

Grouped HCPCS / J Codes — excerptHCPCS

C9095	TEBENTAFUSP-TEBN INJ (group mapping includes J0894)
C9144	EPCORITAMAB-BYSP INJ (group mapping includes J0896)
C9163	TALQUETAMAB-TGVS INJ (group mapping includes J0897)
C9165	ELRANATAMAB-BCMM INJ (group mapping includes J0897)
C9293	GLUCARPIDASE INJ (group mapping includes J1302)
J0185	APREPITANT INJECTION (cross-referenced J1442; FILGRASTIM G-CSF 1 MCG)
J0207	AMIFOSTINE 500 MG INJ (cross-referenced J1447; TBO-FILGRASTIM)
J0881	DARBEPOETIN ALFA 1 MCG INJECTION

Additional HCPCS / J / Q Codes — excerpt (includes required codes J0885, J0888, J0893)HCPCS

J0885	EPOETIN ALFA, 1000 UNITS
J0888	EPOETIN BETA, 1000 UNITS
J0893	DARB/EPOETIN, UNLISTED FORMULATION — verify mapping and review clinical indication
J1954	LEUPROLIDE ACETATE INJ
J8999	UNCLASSIFIED ANTINEOPLASTIC AGENT (multiple entries mapped to specific drugs)
J2506	PEGFILGRASTIM DELIVERY KIT / INJECTION
J2796	ROMIPLOSTIM INJECTION 10 MCG
J2820	SARGRAMOSTIM INJECTION 50 MCG
J7280	(placeholder)

Submission and Authorization Actions for Providers

Prior Authorization

Prior Authorization Required

Oncology medications and supportive agents require review by Evolent (formerly New Century Health [NCH]) before being dispensed at a pharmacy or administered in an outpatient, ambulatory, or physician office setting for members 18 and older (pediatrics will be included starting 7/1/2022).

Prior review required for oncology medications and supportive agents
Includes dispensing at pharmacy and administration in outpatient/ambulatory/physician office settings
Pediatric membership added starting 7/1/2022

Denial Risk

Complete Regimen Submission Required

Providers must submit the complete oncology regimen to New Century Health — include all agents, supportive medications, and schedule details. Omitting any part of the regimen may result in a denial even if individual agents would otherwise be reviewed separately.

Submit the entire regimen (all drugs, doses, frequency, and administration dates)
Omissions or partial regimen submissions may lead to denial

Note

How to Submit Requests to New Century Health

Submit requests to New Century Health (formerly New Century Health) via their web portal or by phone. For portal access, visit my.newcenturyhealth.com. For phone assistance, call 1-888-999-7713.

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

Note

Out-of-Scope Requests — Do Not Submit to NCH

Do NOT submit the following request types to New Century Health (these are out of scope): antibiotics; bone marrow/stem cell transplants; CAR-T cell therapy; Cablivi; controlled substances; equipment requests (infusion pumps); genetic lab testing and laboratory services; hemophilia drugs; immune globulins; inpatient drug requests; iron preparations; pain medications; radiopharmaceuticals; surgeries/surgical procedures; sickle cell diagnoses.

Out-of-Scope Items and Definitions

Items NOT to submit to New Century Health

AntibioticsDo not submit antibiotic requests to New Century Health; these are out of scope.

Bone marrow/stem cell transplants & CAR‑T therapyRequests for transplants and CAR‑T cell therapy should NOT be submitted to New Century Health.

Controlled substancesControlled substance medication requests are out of scope and should not be sent to NCH.

Inpatient drug requestsDrugs administered in the inpatient setting are not to be submitted to New Century Health.

RadiopharmaceuticalsRequests for radiopharmaceuticals are excluded from NCH review and should not be submitted.

Genetic lab testing and laboratory servicesGenetic testing and related laboratory services are out of scope for submission to New Century Health.

Equipment requests (infusion pumps)Requests for equipment such as infusion pumps should NOT be submitted to New Century Health.

Background and Scope

This policy defines the administrative prior review process for oncology medications and supportive agents for Fidelis Care Medicaid Managed Care & HealthierLife members. It is administrative in intent and does not provide clinical treatment guidance; rather, it specifies which therapies (by HCPCS/J/Q/G codes) require review and which categories are excluded from New Century Health review.

Oncology medications and supportive agents require review by Evolent (formerly New Century Health) before being dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting for members 18 and older. Pediatric membership is included beginning 7/1/2022. Requests must be submitted via NCH's web portal or by phone, and the entire oncology regimen must be submitted; omissions may result in a denial.