CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents prior review / authorization requirements

Defines drugs and HCPCS/CPT/J-codes requiring review by Evolent/New Century Health for Fidelis Care (Wellcare) Medicare members and lists preferred biosimilars and out-of-scope items. Affects participating providers who dispense or administer oncology medications.

Policy Summary

PayerFidelis Care (Wellcare)

PolicyOncology medications and supportive agents prior review / authorization requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date11/1/2024

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent (New Century Health) for review prior to dispensing or administration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+listed HCPCS/CPT/J-codes requiring review

2benefit types noted

1external review vendor

Multiplepreferred biosimilar groups

Coverage and Administrative Requirements

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Prior Review / Authorization Requirement

Covered when the following administrative conditions are met

Administrative review requirements: The listed oncology medications and supportive agents require review by Evolent (formerly New Century Health) prior to dispensing at a pharmacy or administration in physician office/outpatient/ambulatory settings for members of all ages.

Requests can be submitted via NCH web portal (my.newcenturyhealth.com) or by phone at 1-888-999-7713, option 1. If non-participating provider, submit to the plan via fax per plan instructions.

Complete regimen submission: Submit the entire oncology regimen to Evolent (formerly NCH) for review; omissions of regimen components may result in denial.

Include all agents (oncology and supportive care) when submitting for review.

Codes requiring review: Requests for the oncology medications and supportive agents identified by HCPCS/CPT/J-codes and Q-codes in this policy (including examples such as J0185, J0881, J0885, J2506, J9211, J9271, J9305, Q5107, Q5126, J8999 and others listed) must be submitted to NCH for prior review before dispensing or administration.

See coding section for full code lists and examples.

This policy identifies items that are out of scope for review by New Century Health (NCH). Do NOT submit requests for these items to NCH. Examples include: antibiotics, bone marrow/stem cell transplants and CAR‑T cell therapy, controlled substances (e.g., morphine), equipment requests such as infusion pumps, and genetic testing and laboratory services.

Also excluded from NCH review are hemophilia drugs, inpatient drug requests, inpatient radiation and chemotherapy treatments, iron preparations, radiopharmaceuticals, surgeries/surgical procedures, sickle cell diagnoses and therapies, and immune globulins.

Regimen / Submission requirement	Preferred biosimilar groups (examples)
Entire oncology regimen must be submitted to Evolent (formerly New Century Health) for review prior to dispensing or administration; submit the full regimen regardless of prior authorization requirement — omissions may result in denial.
Requests for listed oncology medications and supportive agents require review by Evolent/NCH before being dispensed at a pharmacy or administered in physician office/outpatient/ambulatory settings.
Submit via NCH web portal (my.newcenturyhealth.com) or by phone (1-888-999-7713, option 1). Non‑participating providers submit to plan (fax 1-844-235-5090).
Erythropoiesis-stimulating agents: (examples listed under review list include epoetin/darbepoetin products).	Erythropoiesis-stimulating agents (epoetin alfa, darbepoetin alfa) — preferred biosimilars noted where applicable.
Trastuzumab: biosimilar Q-codes listed in policy.	Trastuzumab biosimilars (e.g., Q5112 trastuzumab-dttb) — preferred biosimilar codes included.
Bevacizumab: biosimilar Q-codes listed in policy.	Bevacizumab biosimilars (e.g., Q5107, Q5126) — preferred biosimilars identified.
Hematopoietic agents (filgrastim/pegfilgrastim): biosimilar Q-codes listed.	Filgrastim/pegfilgrastim biosimilars (e.g., Q5108, Q5110) — preferred biosimilars listed.
Rituximab: medical and pharmacy benefit products listed.	Rituximab biosimilars (e.g., Q5115 rituximab-abbs) — preferred biosimilars noted.
Bone agents and prostate cancer agents, bendamustine, and antiemetics are included in the review list and should be submitted as part of the regimen.	Bone agents and other classes may have preferred agents listed (see policy codes and examples).

Provider Submission and Authorization Actions

Prior Authorization

Prior authorization / review required by Evolent/NCH

Requests for the listed oncology medications and supportive agents must be reviewed by Evolent (formerly New Century Health) prior to being dispensed at a pharmacy or administered in a physician office, outpatient hospital, or ambulatory setting for members of all ages. Submit requests via the NCH web portal (my.newcenturyhealth.com) or by calling 1-888-999-7713, option 1; non-participating providers should submit to the plan per fax instructions in the policy.

Applies to J- and Q-codes and listed agents referenced in the policy (see coding tables).
Review is required regardless of formulary status to establish use for a medically accepted indication.

Step Therapy

Submit preferred biosimilar agents to NCH for review

Preferred biosimilar agents are identified for certain product classes (e.g., trastuzumab, bevacizumab, pegfilgrastim/filgrastim, rituximab and other biosimilars). Providers are instructed to submit preferred biosimilar agents to New Century Health for review.

Examples shown in the policy: Q5107/Q5126 (bevacizumab biosimilars), Q5108/Q5110/Q5112/Q5115 (pegfilgrastim/filgrastim/trastuzumab/rituximab biosimilars).
Submit the specific biosimilar product you intend to use when requesting review.

Documentation Required

Submit full oncology regimen to Evolent/NCH

Submit the entire oncology regimen to Evolent (formerly New Century Health) for review prior to dispensing or administration.

This requirement applies regardless of whether individual agents would otherwise require prior authorization.
Requests can be submitted via NCH web portal or phone (see contact information).

Denial Risk

Incomplete regimen submissions risk denial

Omitting any portion of the oncology regimen when submitting to Evolent may result in a denial of the request.

The policy NOTE explicitly states: 'Any omissions may result in a denial.'
Ensure all supportive agents and schedule details are included in the submission.

Regimen Submission Requirements and Preferred Agents

Requirement	Details / Examples
Complete regimen submission required	Submit the entire oncology regimen to Evolent (formerly New Century Health) for review prior to dispensing or administration; any omissions may result in denial.
Prior authorization / review applies to listed agents	The listed oncology medications and supportive agents require review by Evolent/NCH before being dispensed at a pharmacy or administered in outpatient/ambulatory settings for members of all ages.
Preferred biosimilar groups — trastuzumab	Trastuzumab biosimilars included (example Q5112 trastuzumab-dttb).
Preferred biosimilar groups — bevacizumab	Bevacizumab biosimilars included (examples Q5107, Q5126).
Preferred biosimilar groups — pegfilgrastim/filgrastim	Pegfilgrastim/filgrastim biosimilars included (examples Q5108, Q5110).
Preferred biosimilar groups — rituximab	Rituximab biosimilars included (example Q5115 rituximab-abbs); rituximab products appear under both medical and pharmacy benefit lists.
Other included classes	Erythropoiesis-stimulating agents, bone agents, prostate cancer agents, bendamustine, and antiemetics are included in the review list and may have preferred products noted in the policy.
How to submit	Requests can be submitted via NCH web portal at my.newcenturyhealth.com or by calling 1-888-999-7713, option 1; non-participating providers submit to the plan (fax 1-844-235-5090).

Out-of-Scope Items and Definitions

Out of scope for NCH

AntibioticsDo NOT submit antibiotic requests to New Century Health (NCH).

Cellular therapies and transplantsBone marrow/stem cell transplants and CAR‑T cell therapy are out of scope and should not be submitted to NCH.

Controlled substancesRequests for controlled substances (e.g., morphine) should NOT be submitted to NCH.

Durable medical equipmentEquipment requests (for example, infusion pumps) are out of scope for NCH and should not be submitted.

Genetic and laboratory testingGenetic lab testing and other laboratory services are excluded from NCH review and should not be submitted.

Inpatient services and drugsInpatient drug requests and inpatient radiation or chemotherapy treatments are out of scope and must not be submitted to NCH.

Other excluded categories (most actionable)Do NOT submit requests for hemophilia drugs, iron preparations, radiopharmaceuticals, surgeries/surgical procedures, sickle cell diagnoses/therapies, immune globulins to NCH.

OpenPayer

Oncology medications and supportive agents prior review / authorization requirements

Coverage and Administrative Requirements

Codes and Billing Groups Requiring Review

Provider Submission and Authorization Actions

Regimen Submission Requirements and Preferred Agents

Out-of-Scope Items and Definitions

Policy Background

Q5108	PEGFILGRASTIM-JMDB
Q5110	FILGRASTIM-AAFI (NIVESTYM BIOSIMILAR)
Q5112	TRASTUZUMAB-DTTB
Q5115	RITUXIMAB-ABBS

J8999	NIROGACESTAT ORAL
J8999	OLAPARIB TABS ORAL
J8999	OLUTASIDENIB ORAL
J8999	OSIMERTINIB ORAL
J8999	PALBOCICLIB ORAL
J8999	RIBOCICLIB ORAL
J8999	IBRUTINIB ORAL
J8999	LENALIDOMIDE ORAL
J8999	VENETOCLAX ORAL
J8999	TAMOXIFEN ORAL