CurrentFidelis CarePolicy N/A

Medicare Wellcare by Fidelis Care Oncology Medications and Supportive Agents Review

Requires review by Evolent (formerly New Century Health) for oncology medications and supportive agents for participating providers prior to dispensing or administration across medical and pharmacy benefits; lists drugs/HCPCS/J-codes requiring review and drugs out of scope. Applies to Medicare Wellcare by Fidelis Care members effective 3/1/2024.

Policy Summary

PayerFidelis Care

PolicyMedicare Wellcare by Fidelis Care Oncology Medications and Supportive Agents Review

Policy CodePolicy N/A

Change TypeAdministrative notice (no material change)

Effective Date3/1/2024

Next Review Date

Key ActionParticipating providers must submit all oncology medication and supportive agent requests, including the entire regimen, to Evolent (New Century Health) for review prior to dispensing or administration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — policy remains a centralized review requirement with no substantive changes listed.

ExtensiveNumber of listed codes requiring review

3/1/2024Effective date

1Required review vendor (Evolent / NCH)

Policy summary

Medicare Wellcare by Fidelis Care requires centralized clinical review by Evolent (formerly New Century Health) for oncology medications and supportive agents prior to dispensing at a pharmacy or administration in physician office, outpatient hospital, or ambulatory settings effective 2024-03-01.

The requirement applies across both medical and pharmacy benefits and includes a comprehensive list of HCPCS/J-codes and oral oncology agents that must be submitted for review; participating providers must submit requests to Evolent (NCH) before dispensing/administration, while non-participating providers follow the plan fax submission process as noted.

Effective date3/1/2024

Required review vendorEvolent (formerly New Century Health)

Scope summaryRequires review by Evolent (formerly New Century Health) for oncology medications and supportive agents for participating providers prior to dispensing or administration across medical and pharmacy benefits; lists drugs/HCPCS/J-codes requiring review and drugs out of scope. Applies to Medicare Wellcare by Fidelis Care members effective 3/1/2024.

StatusCURRENT

Number of listed codes requiring reviewExtensive

Required review vendor (stat)1

Review requirements and scope

Review requirement for oncology medications and supportive agents

Requests require review by Evolent (formerly New Century Health) prior to dispensing or administration for participating providers:

ALL of the following

Review required by Evolent (New Century Health) for oncology medications and supportive agents before being dispensed at a pharmacy or administered in physician office, outpatient hospital, or ambulatory setting for members of all ages
Requests can be submitted via mynewcenturyhealth.com portal or by phone 1-888-999-7713 option 1; non-participating providers submit to plan fax 1-844-235-5090 (effective 10/1/2023)
Submit entire regimen: Submit the entire oncology regimen to Evolent; omissions may result in a denial
Clinical trials may be sent to Evolent for review

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Out of scope (Do NOT submit to New Century Health)

The following request types are out of scope and should NOT be submitted to NCH:

ANY of the following

Antibiotics
Bone marrow / stem cell transplants and CAR-T cell therapy
Equipment requests (infusion pumps)
Controlled substances (e.g., Morphine)
Genetic lab testing and laboratory services

Drugs requiring NCH review (medical or pharmacy benefit)

The following HCPCS/J-codes require review by NCH regardless of formulary status (available via medical or pharmacy benefit):

HCPCS / J-codes requiring review: See code groups for full code list

Full HCPCS/J-code list available in the code_groups section of the policy

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Drugs requiring NCH review (pharmacy benefit only)

The following drugs (listed by J-code or oral agent) require review by NCH before being dispensed at a pharmacy (pharmacy benefit only):

Oral and pharmacy-only oncology agents: See code groups for full code list

Full oral/pharmacy-only agent list available in the code_groups section of the policy

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HCPCS / J-codes and oral agents requiring review

HCPCS / J-codes requiring review (medical or pharmacy benefit)HCPCSCovered

C9142	BEVACIZUMAB-MALY (listed with J0642, LEVOLEUCOVORIN INJ etc.)
C9146	MIRVETUXIMAB SORAVTANSINE-GYNX (with J0881, DARBEPOETIN ALFA NON-ESRD)
C9147	TREMELIMUMAB-ACTL INJECTION (with J0885, EPOETIN ALFA NON-ESRD)
C9148	TECLISTAMAB-CQYV INJECTION (with J0888, EPOETIN BETA NON-ESRD - MIRCERA)
C9155	EPCORITAMAB-BYSP (with J0893, DECITABINE INJ)
C9163	TALQUETAMAB-TGVS INJ (with J0894, DECITABINE INJ)
C9165	ELRANATAMAB-BCMM INJ (with J0896, LUSPATERCEPT-AAMT)
C9293	GLUCARPIDASE (with J0897, DENOSUMAB PROLIA)
J0185	APREPITANT INJ (linked to J0897 DENOSUMAB XGEVA)
J0207	AMIFOSTINE INJ (linked J1246, INJ DINUTUXIMAB)

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1/14

Oral and pharmacy-only oncology agents requiring review (pharmacy benefit only)mixedCovered

J7520	SIROLIMUS ORAL
J7527	SIROLIMUS ORAL (alternate listing)
J8501	APREPITANT ORAL (5 mg / suspension / tripak listings)
J8530	CYCLOPHOSPHAMIDE ORAL
J8565	GEFITINIB
J8600	MELPHALAN ORAL
J8655	NETUPITANT-PALONOSETRON ORAL
J8999	Multiple oral oncology agents mapped to J8999 for billing (long list includes DACOMITINIB, DAROLUTAMIDE, DECITABINE CEDAZURIDINE, DUVELISIB, EFLORNITHINE, ELACESTRANT, ENASIDENIB, ENCORAFENIB, ENTRECTINIB, ABEMACICLIB, ABIRATERONE ACETATE, ABIRATERONE MICRONIZED, ABIRATERONE, ACALABRUTINIB, ACITRETIN, ADAGRASIB, AFATINIB, ALECTINIB, ALPELISIB, ANASTROZOLE, APALUTAMIDE, ASCIMINIB, AVAPRITINIB, AXITINIB, AZACITIDINE ORAL and many others)

What providers must do

Prior Authorization

Mandatory review by Evolent (NCH)

Participating providers must submit all oncology medication and supportive agent requests to Evolent (New Century Health) for review prior to dispensing or administration.

Submit the entire oncology regimen to avoid denial; omissions may result in a denial.
Applies to pharmacy dispensing and administration in outpatient, ambulatory, and physician office settings.

Documentation Required

Submission methods and non-participating providers

Requests can be submitted via NCH's web portal or by phone; non-participating providers must fax requests to the plan (effective 10/1/2023).

Web portal: mynewcenturyhealth.com
Phone: 1-888-999-7713, option 1
Fax (non-participating providers, effective 10/1/2023): 1-844-235-5090

Denial Risk

Omission denial risk

Failure to submit the entire oncology regimen to Evolent may result in claim denial.

Omissions of drugs from the submitted regimen may trigger denials.

Definitions and context

Definitions

TermEvolent (formerly New Century Health, NCH)

DefinitionVendor responsible for clinical review/prior authorization of oncology medications and supportive agents for participating providers.

Wellcare by Fidelis Care has contracted Evolent (formerly New Century Health) to perform centralized clinical review and prior authorization for oncology medications and supportive agents to establish medical indication and manage utilization; participating providers must submit the entire oncology regimen to Evolent to avoid potential denials.

Policy Summary

PayerFidelis Care

PolicyMedicare Wellcare by Fidelis Care Oncology Medications and Supportive Agents Review

Policy CodePolicy N/A

Change TypeAdministrative notice (no material change)

Effective Date3/1/2024

Next Review Date

SourceLink

On This Page

OpenPayer

Medicare Wellcare by Fidelis Care Oncology Medications and Supportive Agents Review

Policy summary

Material change summary

Review requirements and scope

HCPCS / J-codes and oral agents requiring review

What providers must do

Definitions and context

Document history