CurrentFidelis CarePolicy N/A

Essential Plan and Qualified Health Plans Oncology medication prior authorization and HCPCS/J-code list

Requires New Century Health (NCH) review/authorization for oncology medications and supportive agents dispensed in pharmacy or administered in office/outpatient/ambulatory settings for members (18+; pediatric inclusion from 2022-07-01). Provides an extensive HCPCS/J-code listing of drugs that require authorization and lists out-of-scope items and preferred biosimilars.

Policy Summary

PayerFidelis Care

PolicyEssential Plan and Qualified Health Plans Oncology medication prior authorization and HCPCS/J-code list

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must obtain review/authorization from New Century Health (NCH) prior to dispensing or administering listed oncology medications/supportive agents via NCH web portal or phone and submit the entire oncology regimen to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — policy continues to require NCH review for listed oncology medications and supportive agents.

100+Authorized HCPCS/J-code entries listed

1Required external reviewer (New Century Health)

2022-07-01Pediatric inclusion effective

Policy summary & scope

Fidelis Care requires oncology medications and supportive agents to be reviewed by New Century Health (NCH) prior to dispensing or administration for Essential Plan and Qualified Health Plan members; requests must be submitted to NCH via their web portal (mynewcenturyhealth.com) or by phone (1-888-999-7713, option 1). This requirement applies to medications dispensed at a pharmacy or administered in a physician office, outpatient hospital, or ambulatory setting. The policy applies to members aged 18 and older, with pediatric membership (and clinical trials review) included effective 2022-07-01. Providers must submit the entire oncology regimen to NCH prior to dispensing/administration to avoid possible denial.

Policy summary

PayerFidelis Care

PolicyOncology medication prior authorization for Essential Plan and QHPs

Required reviewerNew Century Health (NCH)

SettingsPharmacy; physician office; outpatient hospital; ambulatory

Member age18+ (pediatric inclusion effective 2022-07-01)

Submission methodsNCH web portal (mynewcenturyhealth.com) or phone 1-888-999-7713, option 1

Effective date / Policy numberN/A

Authorization requirement

Requests must be submitted to New Century Health (NCH) prior to dispensing/administration for applicable members; submit entire oncology regimen.

ALL of the following

Member is enrolled in Essential Plan or Qualified Health Plan
Drug is an oncology medication or supportive agent intended to be dispensed at a pharmacy or administered in physician office, outpatient hospital, or ambulatory setting
Request submitted to New Century Health (NCH) via web portal (mynewcenturyhealth.com) or phone (1-888-999-7713, option 1) prior to dispensing/administration
Submit entire oncology regimen to NCH (omissions may result in denial)
Explicit requirement; failure to submit entire regimen may result in denial
Age applicability (effective dates noted)
- Member aged 18 or older (current requirement)
- Pediatric membership will be included starting 2022-07-01 (clinical trials may be sent to NCH for review effective 2022-07-01)
  Clinical trials may be sent to NCH for review effective 7/1/2022

Prior Authorization

Obtain pre-dispense/administration authorization from New Century Health

Providers must obtain review/authorization from New Century Health (NCH) prior to dispensing or administering listed oncology medications/supportive agents. Submit requests to NCH via the web portal or by phone before dispensing/administration; submit the entire regimen for review.

Web portal: mynewcenturyhealth.com
Phone: 1-888-999-7713 (option 1)
Note: Submit the entire oncology regimen to NCH

Documentation Required

Submit the entire oncology regimen to NCH

The entire oncology regimen must be submitted to NCH for review; failing to include the full regimen or omitting agents may result in a denial of the request. This applies to regimen submissions per NCH requirements (pediatric/clinical trial inclusion noted effective 2022-07-01).

Submit entire regimen
Omissions may result in denial
Pediatric membership/clinical trials inclusion effective 2022-07-01

Out-of-scope items (Do not submit to NCH)

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

ANY of the following

Antibiotics
Bone marrow, stem cell transplants, CAR-T cell therapy
Cablivi
Controlled substances
Equipment requests (infusion pumps)
Genetic lab testing and laboratory services
Hemophilia drugs
Immune globulins
Inpatient drug requests
Iron preparations
Pain medications
Radiopharmaceuticals
Surgeries / surgical procedures
Sickle cell diagnoses

Billing Rule

Do not submit out-of-scope request types to NCH

The policy lists specific request types that are out of scope and should NOT be submitted to NCH. Billing and clinical staff should not send these request types to NCH for authorization.

Examples of out-of-scope items: Antibiotics; Bone marrow/stem cell transplants and CAR-T; Controlled substances; Equipment requests (infusion pumps); Genetic lab testing and laboratory services; Hemophilia drugs; Immune globulins; Inpatient drug requests; Radiopharmaceuticals; Surgeries/surgical procedures; Sickle cell diagnoses

Preferred biosimilar agents (oncology-related indications)

The following biosimilars are listed as preferred for oncology-related indications:

ANY of the following

Bevacizumab: Mvasi and Zirabev
Trastuzumab: Kanjinti, Ogivri, Trazimera
Rituximab: Ruxience, Truxima, Riabni
Filgrastim: Medical benefit Zarxio; Pharmacy benefit Nivestym
Pegfilgrastim: Medical benefit Fulphila, Udenyca, Ziextenzo, Nyvepria; Pharmacy benefit Neulasta, Neulasta Onpro, Udenyca

Documentation Required

Preferred biosimilars may affect authorization and billing

The policy identifies preferred biosimilars for oncology-related indications; this preference may affect authorization and billing decisions, so providers should use the preferred biosimilars when appropriate or be prepared to justify non-preferred choices.

Bevacizumab: Mvasi, Zirabev
Trastuzumab: Kanjinti, Ogivri, Trazimera
Rituximab: Ruxience, Truxima, Riabni
Filgrastim: Zarxio (medical benefit); Nivestym (pharmacy benefit)
Pegfilgrastim: Fulphila, Udenyca, Ziextenzo, Nyvepria (medical); Neulasta, Neulasta Onpro, Udenyca (pharmacy)

HCPCS / J-code groups requiring authorization

HCPCS/CPT/J-codes requiring authorization (listed explicitly in policy)HCPCSCovered

C9095	TEBENTAFUSP-TEBN INJ
J0881	Misc J-code referenced under C9095 mapping
J0185	APREPITANT INJECTION
J0207	AMIFOSTINE 500 MG INJ / J0885 mapping / EPOETIN ALFA FOR NON-ESRD (EPOGEN)
J0594	BUSULFAN MG INJ / J0885 mapping / EPOETIN ALFA FOR NON-ESRD (PROCRIT)
J0641	LEVOLEUCOVORIN CALCIUM INJECTION / J0888 mapping / EPOETIN BETA NON-ESRD (MIRCERA)
J0642	LEVOLEUCOVORIN / J0893 mapping / DECITABINE INJECTION
J0896	LUSPATERCEPT-AAMT
J8520	CAPECITABINE ORAL 150 MG
J8521	CAPECITABINE ORAL 500 MG

1–10 of 159

1/16

HCPCS / Codes explicitly mapped to J8999 or other groupings (informational mapping)mixed

J8999

Used as a placeholder for many oral/IV oncology agents listed by name in policy; mapping entries indicate provider should reference the policy mapping when billing

Billing Rule

Reference policy mapping when billing J8999-mapped agents

Many oncology agents in the policy are mapped to J8999 as a placeholder code. When billing, providers must reference the policy's code mapping guidance rather than relying solely on J8999 to ensure correct billing and authorization handling.

J8999 is used as a placeholder for numerous oral/IV oncology agents listed by name in the policy; follow the policy mapping guidance when billing

Actionable instructions for providers

Documentation Required

Submission detail reminder: include full regimen and code references

The entire oncology regimen must be submitted to NCH and omissions may lead to denial; include relevant HCPCS/J-code(s) and mapped entries (including J8999 mappings) when submitting to avoid delays or denials.

Submit entire regimen to NCH (see criteria_trees)
Include HCPCS/J-code(s) from the policy listing and reference J8999 mapping where applicable

Policy Summary

PayerFidelis Care

PolicyEssential Plan and Qualified Health Plans Oncology medication prior authorization and HCPCS/J-code list

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Essential Plan and Qualified Health Plans Oncology medication prior authorization and HCPCS/J-code list

Policy summary & scope

Authorization requirement

Out-of-scope items (Do not submit to NCH)

Preferred biosimilar agents (oncology-related indications)

HCPCS / J-code groups requiring authorization

Definitions

Actionable instructions for providers

Revision history