CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents prior authorization and New Century Health (NCH) review

Governs New Century Health (NCH) review and prior authorization requirements for oncology medications and supportive agents for Wellcare by Fidelis Care Medicare members; applies to participating providers and covers drugs administered in clinic or dispensed at pharmacy.

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior authorization and New Century Health (NCH) review

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2023

Next Review DateN/A

Key ActionSubmit oncology medication requests and the complete regimen to New Century Health via their web portal or phone for prior review before dispensing or administration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

hundredsHCPCS/Codes listed requiring review

allMember ages covered

7/1/2023Effective date

web/phoneSubmission methods

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

NCH review/prior authorization requirement

Covered when ALL of the following are met

NCH review required: The listed oncology medication or supportive agent is submitted to New Century Health for review prior to being dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting.

Applies to members of all ages; includes medical or pharmacy benefit as specified.

Do NOT submit the following categories of requests to New Century Health (NCH): antibiotics; bone marrow/stem cell transplants and CAR‑T cell therapy; controlled substances (e.g., morphine); equipment requests (e.g., infusion pumps); genetic testing and laboratory services; hemophilia drugs; inpatient drug requests; inpatient radiation and chemotherapy treatments; iron preparations; radiopharmaceuticals; surgeries/surgical procedures; sickle cell diagnoses and therapies; and immune globulins.

Biosimilar group / class	Preferred agent(s) — medical benefit	Preferred agent(s) — pharmacy benefit	Coverage note
Erythropoiesis-stimulating agents
Retacrit (if unavailable due to shortage: Epogen)
Procrit
Preferred agents should still be submitted to New Century Health (NCH) for review prior to dispensing or administration
Trastuzumab
Trazimera
Herceptin; Herceptin Hylecta; Herzuma; Kanjinti; Ogivri; Ontruzant; Trazimera
Preferred agents should still be submitted to New Century Health (NCH) for review prior to dispensing or administration
Bevacizumab
Mvasi; Zirabev
Avastin; Mvasi; Zirabev
Preferred agents should still be submitted to New Century Health (NCH) for review prior to dispensing or administration
Hematopoietic agents
Zarxio
Zarxio
Preferred agents should still be submitted to New Century Health (NCH) for review prior to dispensing or administration
Rituximab
Ruxience; Truxima
Riabni; Rituxan; Rituxan Hycela; Ruxience; Truxima
Preferred agents should still be submitted to New Century Health (NCH) for review prior to dispensing or administration
Bone agents
Zoledronic acid; pamidronate
Zoledronic acid; pamidronate; Prolia; Xgeva; risdronate; ibandronate
Preferred agents should still be submitted to New Century Health (NCH) for review prior to dispensing or administration
Prostate cancer agents
Eligard; Firmagon; Lupron; Trelstar; Vantas; Zoladex (nonpreferred: Provenge)
Trelstar; Lupron; abiraterone acetate (non-preferred: abiraterone acetate micronized)
Preferred agents should still be submitted to New Century Health (NCH) for review prior to dispensing or administration
Bendamustine

Bendeka
Preferred agents should still be submitted to New Century Health (NCH) for review prior to dispensing or administration
Antiemetics

Aprepitant; dronabinol; ondansetron (IV and oral); granisetron (IV and oral); metoclopramide (IV and oral); prochlorperazine (IV and oral); scopolamine patch
Preferred agents should still be submitted to New Century Health (NCH) for review prior to dispensing or administration

Provider Actions and Submission Requirements

Prior Authorization

Prior authorization / NCH review required

Oncology medications and supportive agents listed by HCPCS/CPT/other codes require review by New Century Health (NCH) prior to being dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting; this applies to members of all ages and includes drugs available via medical or pharmacy benefit.

Step Therapy

Preferred biosimilars — submit to NCH for review

Preferred biosimilar agents are identified for several classes (e.g., erythropoiesis-stimulating agents, trastuzumab, bevacizumab, hematopoietic agents, rituximab, bone agents, prostate cancer agents, bendamustine, antiemetics); providers must still submit those preferred biosimilar agents to NCH for review.

Examples in policy: Retacrit (medical) / Procrit (pharmacy) for ESAs; Trazimera (medical) and multiple trastuzumab pharmacy biosimilars; Mvasi and Zirabev for bevacizumab.

Documentation Required

Submission contact — NCH web portal and phone

Submit prior authorization and review requests to New Century Health via their web portal at my.newcenturyhealth.com or by phone at 1-888-999-7713, option 1; non-participating providers must submit requests to the plan at 1-877-882-5892.

Denial Risk

Complete regimen submission required

Submit the entire oncology regimen to NCH — omission of any part of the regimen when sending a request may result in a denial.

Definitions / Out of Scope

Out of scope with NCH — do not submit to New Century Health for these categories:

AntibioticsDo NOT submit to New Century Health (out of scope)

Transplants and CAR-TBone marrow/stem cell transplants and CAR‑T cell therapy are out of scope — do NOT submit to NCH

Controlled substancesIncludes opioids (e.g., morphine) — do NOT submit to NCH

Equipment requestsInfusion pumps and similar equipment are out of scope — do NOT submit to NCH

Genetic testing and labsGenetic laboratory testing and laboratory services are out of scope — do NOT submit to NCH

Other excluded categoriesHemophilia drugs; inpatient drug requests; inpatient radiation and chemotherapy; iron preparations; radiopharmaceuticals; surgeries/surgical procedures; sickle cell diagnoses and therapies; immune globulins — do NOT submit to NCH

J9035	BEVACIZUMAB 10 MG
J9036	BENDAMUSTINE INJECTION
J9050	CARFILZOMIB
J9171	DOCETAXEL INJ
J9271	PEMBROLIZUMAB
J9355	ADO-TRASTUZUMAB EMTANSINE
J9356	TRASTUZUMAB INJ
Q5107	EPOETIN ALFA-EPBX (RETACRIT BIOSIMILAR)
Q5110	BEVACIZUMAB - AWWB

J8999	Multiple oral oncology agents listed under J8999 (see document for full list)
J7520	SIROLIMUS ORAL
J7527	EVEROLIMUS ORAL

OpenPayer

Oncology medications and supportive agents prior authorization and New Century Health (NCH) review

Coverage Criteria

Covered Codes and Pharmacy Agents

Provider Actions and Submission Requirements

Background

Definitions / Out of Scope