CurrentFidelis CarePolicy N/A
Medicaid Managed Care & HealthierLife Oncology Medications Prior Authorization List
Defines drugs and HCPCS/CPT/Q-code products that require prior authorization review by Evolent for Fidelis Care Medicaid Managed Care & HealthierLife members (adults; pediatric included starting 7/1/2022). Lists out-of-scope items that should not be submitted and a comprehensive list of HCPCS/CPT/J-codes and Q-codes requiring review.
Policy Summary
PayerFidelis Care
PolicyMedicaid Managed Care & HealthierLife Oncology Medications Prior Authorization List
Policy CodePolicy N/A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionAll oncology medications and supportive agents listed require review by Evolent before dispensing or administration; submit via my.newcenturyhealth.com or call 1-888-999-7713, option 1.
SourceLink
POLICY UPDATE CHANGES
No material clinical/coverage changes.
>300Number of codes listed
1Prior Authorization Vendor (Evolent)
2022-07-01Pediatric inclusion date
Coverage Summary
Defines drugs and HCPCS/CPT/Q-code products that require prior authorization review by Evolent for Fidelis Care Medicaid Managed Care & HealthierLife members. Coverage stance: covered with criteria — oncology medications and supportive agents require Evolent review prior to dispensing or administration.