CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents prior review/authorization (NCH)

Requires participating providers to submit oncology medications and supportive agents (medical or pharmacy benefit) to New Century Health (NCH) for review prior to dispensing or administration; lists agents and HCPCS/CPT/J-codes that require review and items out of scope; affects participating providers and pharmacies administering oncology regimens.

Policy Summary

PayerFidelis Care (Wellcare Medicare)

PolicyOncology medications and supportive agents prior review/authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective Date3/1/2023

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+agents/codes listed

14out-of-scope categories

Medical & Pharmacybenefit types

2023-03-01policy effective

Coverage criteria and scope

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Prior Authorization / NCH Review

Covered when reviewed/approved by NCH prior to dispensing or administration.

NCH review requirement: Oncology medications and supportive agents listed in this document require review by New Century Health (NCH) for participating providers before being dispensed at a pharmacy or administered in a physician office, outpatient hospital, or ambulatory setting for members of all ages.

Requests can be submitted via NCH web portal (mynewcenturyhealth.com) or by phone at 1-888-999-7713, option 1; non‑participating providers submit to the plan at 1-877-882-5892.

Complete regimen submission: The entire oncology regimen (medical or pharmacy benefit) must be submitted to NCH regardless of prior authorization requirement.

Omitting parts of the oncology regimen when submitting to NCH may result in a denial.

Drugs subject to review: Drugs listed by HCPCS/J-codes and oral agent lists in this policy are subject to NCH review to establish use for a medically accepted indication prior to dispensing or administration.

See the policy code lists for specific HCPCS/J-codes and oral agents that require review.

Regimen	Coverage status	Notes / Provider action
All oncology regimens — submit complete regimen to NCH to establish medical indication and prior authorization needs
Entire oncology regimens (medical or pharmacy benefit) must be submitted to New Century Health (NCH) for review regardless of prior authorization requirement
Submit the complete oncology regimen via NCH web portal (mynewcenturyhealth.com) or phone (1-888-999-7713, option 1). Omitting parts of the regimen may result in denial; non‑participating providers should submit to the plan at 1-877-882-5892.

The following items are explicitly out of scope and should NOT be submitted to New Century Health (NCH): 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; Surgeries/surgical procedures; Radiopharmaceuticals; Sickle cell diagnoses and therapies; and Immune globulins

This document does not state any explicit not medically necessary criteria. No treatments or indications are labeled within the policy text as not medically necessary.

Codes and drug lists requiring review

Sample listed HCPCS/J-codes (full list continues in document)HCPCS

C9142	BEVACIZUMAB-MALY (as listed)
J0185	APREPITANT INJ (as listed)
J0207	AMIFOSTINE INJ (as listed)
J0594	BUSULFAN INJ (as listed)
J0641	LEVOLEUCOVORIN INJ (as listed)
J0642	LEVOLEUCOVORIN INJ (as listed)
J0881	DARBEPOETIN ALFA NON-ESRD (as listed)
J0885	EPOETIN ALFA NON-ESRD (as listed)
J0888	EPOETIN BETA NON-ESRD (MIRCERA) (as listed)
J0893	DECITABINE INJ (as listed)

1–10 of 11
1/2

Additional HCPCS/J-codes listedHCPCS

J9035	BEVACIZUMAB 10 MG (as listed)
J9040	BLEOMYCIN SULFATE INJ (as listed)
J9312	RITUXIMAB INJECTION (as listed)
J9355	TRASTUZUMAB INJ (as listed)
Q5101	FILGRASTIM-SNDZ (as listed)
J9999	Various - e.g., BEVACIZUMAB ADCD, others listed under J9999

Oral agents / pharmacy benefit codesHCPCS | mixed

J8999	Multiple oral oncology agents (listed individually in document under J8999 class)
J7527	EVEROLIMUS ORAL (as listed)
J8501	APREPITANT ORAL (as listed)

What providers must do

Prior Authorization
Prior Authorization Required — NCH review for oncology medications
Oncology medications and supportive agents (medical or pharmacy benefit) must be submitted to New Century Health (NCH) for review prior to dispensing or administration for participating providers. Submit the entire oncology regimen to NCH via the NCH web portal (mynewcenturyhealth.com) or by phone at 1-888-999-7713, option 1. Non-participating providers should submit requests to the plan at 1-877-882-5892.
Applicable to members of all ages
Includes clinical trials submissions to NCH for review
Submission methods: NCH web portal or 1-888-999-7713, option 1; non‑participating provider plan contact: 1-877-882-5892

Note
Preferred biosimilars — submit for review
Preferred biosimilar agents are listed below and remain preferred; however, these agents must still be submitted to NCH for review prior to dispensing/administration.
Erythropoiesis‑stimulating agents (medical benefit): Retacrit (if unavailable due to shortage: Epogen). Pharmacy benefit: Procrit.
Trastuzumab: Medical benefit: Trazimera. Pharmacy benefit: Herceptin, Herceptin Hylecta; Herzuma, Kanjinti, Ogivri, Ontruzant; Trazimera.
Bevacizumab: Medical benefit: Mvasi, Zirabev. Pharmacy benefit: Avastin, Mvasi, Zirabev.
Hematopoietic agents: (see NCH submission)

Denial Risk
Submit entire oncology regimen — omissions may result in denial
Submit the entire oncology regimen to NCH regardless of whether individual agents appear to require prior authorization. Omitting components of the regimen when submitting to NCH may result in a denial. When preparing a request, include the full regimen and all supportive agents, and reference applicable HCPCS/J‑codes as needed.
Omissions of regimen components may result in claim denial
Provide full regimen details and relevant HCPCS/J‑codes when submitting to NCH

Definitions and key terms

NCH review — Definition

DefinitionReview by New Century Health (NCH) required prior to dispensing or administration of listed oncology medications and supportive agents for participating providers.

ScopeApplies to oncology medications and supportive agents whether provided under the medical or pharmacy benefit; applies to members of all ages.

Submission methodsRequests must be submitted to NCH via the NCH web portal (mynewcenturyhealth.com) or by phone at 1-888-999-7713, option 1 (non‑participating providers submit to the plan at 1-877-882-5892).

Provider requirementSubmit the entire oncology regimen to NCH for review; omission of regimen components may result in denial.

Exceptions / out-of-scope itemsDo NOT submit the following to NCH: antibiotics; bone marrow/stem cell transplants and CAR‑T therapy; equipment requests (infusion pumps); controlled substances; genetic lab testing and laboratory services; inpatient drug requests; hemophilia drugs; inpatient radiation/chemotherapy treatments; iron preparations; surgeries; radiopharmaceuticals; sickle cell diagnoses/therapies; immune globulins.

Policy Summary

PayerFidelis Care (Wellcare Medicare)

PolicyOncology medications and supportive agents prior review/authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective Date3/1/2023

Next Review DateN/A

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

SourceLink

On This Page

OpenPayer

Oncology medications and supportive agents prior review/authorization (NCH)

Coverage criteria and scope

Codes and drug lists requiring review

What providers must do

Definitions and key terms

Policy background