CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents prior review (New Century Health / Evolent)

This policy governs prior review (authorization) requirements for oncology medications and supportive agents for Medicare Wellcare by Fidelis Care members and specifies drugs that require review by Evolent (formerly New Century Health) before dispensing or administration; it applies to participating providers and describes submission channels and out-of-scope items.

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior review (New Century Health / Evolent)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2024

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent (NCH) for review via the NCH web portal or phone before dispensing or administration; omissions may result in denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

medical & pharmacy listsMedical & pharmacy scope

portal and phonePrior review channels

14+Out-of-scope items

HCPCS/J-codesCode groups

Drugs and Requests Requiring Review

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Drugs requiring NCH review (medical benefit or pharmacy benefit)

Covered when review by New Century Health (Evolent) is obtained for the listed agents prior to dispensing or administration.

Primary requirement: Provider must submit the entire oncology regimen to Evolent (New Century Health) for review prior to dispensing or administration for members of all ages.

Submission may be completed via NCH web portal or by phone; non‑participating providers should use the plan fax.

The following request types are out of scope for New Century Health (Evolent) and should NOT be submitted to NCH for review: antibiotics; bone marrow / stem cell transplants and CAR‑T cell therapy; equipment requests (infusion pumps); controlled substances (e.g., morphine); genetic laboratory testing and laboratory services; inpatient drug requests; hemophilia drugs; inpatient radiation and chemotherapy treatments; iron preparations; radiopharmaceuticals; sickle cell diagnoses and therapies; surgeries/surgical procedures; and immune globulins.

Rule	Notes / Examples
Entire oncology regimen must be submitted to Evolent (formerly New Century Health) for review prior to dispensing or administration.	This requirement applies regardless of whether individual agents in the regimen have separate prior‑authorization status; omissions of regimen components may result in denial.
Submit requests via NCH web portal (mynewcenturyhealth.com) or by phone at 1-888-999-7713, option 1; non‑participating providers use plan fax 1-844-235-5090.	Example: If a multi‑agent chemotherapy regimen includes one agent that normally requires PA and another that does not, send the full regimen together for review rather than only the PA agent.

Relevant HCPCS / J-Codes and Mappings

Covered HCPCS/C codes (partial extract)HCPCSCovered

C9142	BEVACIZUMAB-MALY / J0642 / LEVOLEUCOVORIN INJ
C9146	MIRVETUXIMAB SORAVTANSINE-GYNX / J0881 / DARBEPOETIN ALFA NON-ESRD
C9147	TREMELIMUMAB-ACTL INJECTION / J0885 / EPOETIN ALFA NON-ESRD
C9148	TECLISTAMAB-CQYV INJECTION / J0888 / EPOETIN BETA NON-ESRD (MIRCERA)

Covered J-codes and pharmacy codes (selected examples)HCPCS | mixedCovered

J9035	BEVACIZUMAB 10 MG
J9271	PEMBROLIZUMAB
J9312	RITUXIMAB INJECTION
J8999	Unlisted oral oncology agents (multiple oral targeted therapies listed under J8999)

J9999 and other mappingsHCPCS

J9325	TALIMOGENE LAHERPAREPVEC (mapped to J9999 and mechlorethamine gel in document)
J9354	ADO-TRASTUZUMAB EMTANSINE (document shows Q2043 mapping)
J9999	Multiple mappings for unlisted items (document maps J9999 to numerous products including EPCORITAMAB-BYSP, PEGFILGRASTIM biosimilars, RITUXIMAB variants, and others)

Provider Submission and Compliance Requirements

Prior Authorization

Prior review required for listed oncology drugs

Oncology medications and supportive agents listed in this policy (medical- or pharmacy-benefit) require review by New Century Health (Evolent) before being dispensed or administered to members of all ages.

Requirement applies to dispensing at a pharmacy or administration in physician office, outpatient hospital, or ambulatory settings.

Note

Preferred biosimilars — still require NCH review

Preferred biosimilar agents are identified in the policy but must still be submitted to New Century Health (Evolent) for review.

The policy lists preferred biosimilars for medical and pharmacy benefits (e.g., Retacrit/Procrit, Trazimera/Herceptin biosimilars, Mvasi/Zirabev).

Documentation Required

How to submit oncology prior review requests

Submit oncology prior review requests to New Century Health (Evolent) via their web portal or by phone; non‑participating providers must use the plan fax number.

Web portal: mynewcenturyhealth.com
Phone: 1-888-999-7713, option 1
Non‑participating provider fax (plan): 1-844-235-5090 (formerly 1-877-882-5892)

Denial Risk

Risk of denial if entire regimen omitted

Omitting the entire oncology regimen when submitting to Evolent may result in a denial; submit the full regimen regardless of individual agent prior authorization status.

The policy explicitly instructs: “Please submit the entire oncology regimen to Evolent (formerly NCH)… omissions may result in a denial.”

Regimen Submission Requirements

Coverage requirement	Implication / provider action
Entire regimen must be submitted to Evolent for review regardless of individual agent prior authorization status.	Providers must include all agents and supportive therapies in the submission; failure to include the full regimen may lead to denial of the request.
Requirement covers oncology medications and supportive agents billed under medical or pharmacy benefit listed in this policy (HCPCS/J-codes and oral agents).	Include J‑codes/HCPCS (examples listed in policy) and any oral agents (including items billed under J8999/J9999 mappings) when sending the regimen for NCH review.
Submission channels: NCH web portal or phone; non‑participating providers submit via plan fax as specified in the policy.	Use mynewcenturyhealth.com or call 1-888-999-7713, option 1. Non‑participating providers: fax 1-844-235-5090.

Key Definitions and Participating Provider

Participating provider

DefinitionA participating provider is any provider for whom oncology medications and supportive agents must be reviewed by Evolent (formerly New Century Health) prior to dispensing at a pharmacy or administration in a physician's office, outpatient hospital, or ambulatory setting for members of all ages.

Scope of reviewApplies to oncology medications and supportive agents whether covered under the medical benefit or pharmacy benefit and includes clinical-trial requests submitted to Evolent for review.

Action requiredParticipating providers must submit the entire oncology regimen to Evolent (mynewcenturyhealth.com or 1-888-999-7713, option 1) for review prior to dispensing or administration; omissions may result in a denial.

Settings coveredReview requirement covers drugs dispensed at a pharmacy and drugs administered in physician offices, outpatient hospitals, and ambulatory settings.

Non‑participating providersNon‑participating providers should submit requests to the plan fax (as of 10/1/2023): 1-844-235-5090 (formerly 1-877-882-5892).

Policy Background and Scope

This policy centralizes clinical review of oncology medications and supportive agents through Evolent (formerly New Century Health) to establish medically accepted indications prior to dispensing or administration. It applies to participating providers and to Medicare Wellcare members served by Fidelis Care; participating providers must submit oncology regimens and listed agents to Evolent for review before dispensing or administration.