CurrentFidelis CarePolicy N/A

Oncology medication and supportive agent prior authorization and drug list

Defines Evolent review and prior authorization requirements for oncology medications and supportive agents for Fidelis Care Medicaid Managed Care & HealthierLife members and lists HCPCS/J-codes and related drugs that require authorization or are in-scope/out-of-scope.

Policy Summary

PayerFidelis Care

PolicyOncology medication and supportive agent prior authorization and drug list

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent via the portal or phone to obtain prior authorization and avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+member age affected

multiplelisted drug codes

requiredregimen submission

portal/phonerequest route

Coverage and Scope

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.

Evolent review requirement: Oncology medications and supportive agents require review by Evolent before dispensing at a pharmacy or administration in a physician's office, outpatient hospital, or ambulatory setting for members aged 18 and older (pediatric membership included starting 7/1/2022).

Requests must be submitted via Evolent's web portal (my.newcenturyhealth.com) or by phone (1-888-999-7713, option 1). Submit the entire oncology regimen to Evolent; omission of regimen components may result in a denial.

Regimen requirement	Coverage status	Notes / Rationale
Entire oncology regimen must be submitted to Evolent regardless of individual drug prior authorization requirements
Failure to include all agents in the submitted regimen may result in denial of the request
Submit requests via Evolent portal (my.newcenturyhealth.com) or phone; do not omit regimen components — list all HCPCS/J/Q codes for the regimen

The following items are out of scope for submission to Evolent and should NOT be submitted for prior authorization: antibiotics; bone marrow/stem cell transplants; CAR‑T cell therapy; Cablivi; controlled substances; equipment requests (infusion pumps); testing and laboratory services; hemophilia drugs; immune globulins; inpatient drug requests; iron preparations; pain medications; radiopharmaceuticals; surgeries/surgical procedures; and sickle cell diagnoses.

HCPCS / J- and Q-Code Lists

Listed HCPCS/C codes (sample from chunk 2)mixed

C9173	FILGRASTIM-TXID (NYPOPZI) / J0897 (as listed)
C9293	GLUCARPIDASE / J1010 / METHYLPREDNISOLONE ACETATE (as listed)
J0185	APREPITANT INJECTION (listed)
J0207	INJECTION AMIFOSTINE 500 MG (listed)
J0208	SODIUM THIOSULFATE (listed)

Listed HCPCS/J-codes and Q-codesHCPCS

J2277	MOTIXAFORTIDE INJECTION
J8522	CAPECITABINE ORAL 50 MG
J8999	Unclassified drugs - many specific agents listed under J8999 entries (e.g., ABEMACICLIB, ADAGRASIB, etc.)
J9034	BENDAMUSTINE (RAPID INFUSION BENDEKA) (listed)
J9035	INJECTION BEVACIZUMAB 10 MG
J9301	OBINUTUZUMAB
J9311	RITUXIMAB AND HYALURONIDASE
J9355	TRASTUZUMAB 10 MG
J9999	Miscellaneous drug injections (many oncology agents listed)
Q2017	TENIPOSIDE 50 MG

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What Providers Must Do

Prior Authorization

Evolent prior authorization required — Prior authorization review by Evolent is required before dispensing or administration

Oncology medications and supportive agents require review by Evolent 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 included starting 7/1/2022). Requests must be submitted via Evolent's web portal or by phone.

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

Note

Regimen submission requirement — Providers must submit the entire oncology regimen to Evolent regardless of individual drug prior authorization status

Please submit the entire oncology regimen to Evolent regardless of whether each individual drug requires prior authorization. This means include all agents, supportive medications, and administration-related drugs that are part of the member's planned regimen.

Denial Risk

Regimen omission denial risk — Omitting parts of the oncology regimen when submitting to Evolent may result in a denial.

Omitting parts of the oncology regimen when submitting to Evolent may result in a denial. To avoid denial risk, include all regimen components (chemotherapy agents, supportive care drugs, growth factors, antiemetics, radiopharmaceuticals, etc.) in the single submission.

Note

Submission channel — Requests must be submitted via Evolent's web portal or by phone (portal URL and phone number).

Requests must be submitted via Evolent's web portal or by phone. Use the portal at mynewcenturyhealth.com or call 1-888-999-7713, option 1 for prior authorization requests.

Portal URL: mynewcenturyhealth.com
Phone: 1-888-999-7713, option 1

Policy Background

This policy governs the review and authorization workflow for oncology medications and supportive agents administered in outpatient settings or dispensed from a pharmacy for Fidelis Care Medicaid Managed Care & HealthierLife members. Evolent review and prior authorization are required before dispensing or administration of the listed oncology medications and supportive agents, and providers must submit the entire oncology regimen to Evolent to support the authorization request; omissions may result in denial.

Key Definitions

Evolent review — definition/term

DefinitionEvolent review: Prior authorization review performed by Evolent for oncology medications and supportive agents before dispensing or administration in outpatient settings.

Applies toMembers 18 and older (pediatric membership added effective 7/1/2022).

Settings coveredPharmacy dispensing, physician office, outpatient hospital, and ambulatory settings.

Submission methodsSubmit requests via Evolent web portal (my.newcenturyhealth.com) or by phone at 1-888-999-7713, option 1.

PurposeEnsures Evolent review/authorization is obtained prior to administration or dispensing of oncology therapies and supportive agents.