CurrentFidelis CarePolicy N/A

medicare_wellcare_oncology_medication_review_list

Defines that oncology medications and supportive agents for Medicare Wellcare by Fidelis Care require review by Evolent (formerly New Century Health/NCH) prior to dispensing or administration across medical and pharmacy benefits; lists HCPCS/CPT/J-codes and J8999/J9999/Q-codes requiring review and enumerates items out of scope (do not submit). Effective 1/1/2024 for many code lists; provides submission contact and fax for non-participating providers.

Policy Summary

PayerFidelis Care

Policymedicare_wellcare_oncology_medication_review_list

Policy CodePolicy N/A

Change TypeClarified (effective date/code list update)

Effective DateJan 1, 2024

Next Review Date

Key ActionAll participating providers must submit requests for listed oncology medications/supportive agents to Evolent (formerly New Century Health) for review prior to dispensing or administration; submit the entire oncology regimen to avoid denial.

SourceLink

POLICY UPDATE CHANGES

Effective 1/1/2024 many code lists updated to require NCH review for Wellcare by Fidelis Care.

200+Listed HCPCS/J/Codes requiring review

1Centralized review vendor (Evolent/NCH)

1Non-participating provider fax effective 2023-10-01

Policy Summary & Scope

Wellcare by Fidelis Care requires centralized utilization review of oncology medications and supportive agents through Evolent (formerly New Century Health/NCH) to establish medical necessity across both medical and pharmacy benefits. The policy lists extensive HCPCS/CPT/J/Codes, J8999/J9999 and Q-codes that require NCH review and also enumerates items that are out of scope and should not be submitted. Effective 1/1/2024 many code lists were updated to require NCH review for Wellcare by Fidelis Care.

Requests should be submitted via the NCH web portal at mynewcenturyhealth.com or by phone at 1-888-999-7713 (option 1). If you are a non-participating provider, submit requests to the plan fax at 1-844-235-5090 (effective 10/1/2023).

Operational metadata

Effective Date2024-01-01

VendorEvolent (formerly NCH)

Submission methodsPortal (mynewcenturyhealth.com), Phone 1-888-999-7713 (option 1), Plan fax for non-participating providers 1-844-235-5090 (effective 10/1/2023)

ScopeMedical and pharmacy benefits (on-site administration or pharmacy dispensing)

Headline statsListed HCPCS/J/Codes requiring review: 200+; Single centralized review vendor: 1; Non-participating provider fax effective 2023-10-01

Prior Review & Scope — What Must Be Submitted

General Prior Review Requirement

Covered when ALL of the following are met:

ALL of the following

Medication is listed: Medication is an oncology medication or supportive agent listed in Section III (A or B) or equivalent and is to be dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting for members of any age.
Prior review submission: Request submitted to Evolent (formerly New Century Health/NCH) for review prior to dispensing or administration.
Regimen submission requirement: Entire oncology regimen must be submitted to Evolent (formerly NCH); omissions may result in a denial.
Operational requirement

ref

title

General Prior Review Requirement

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Out-of-Scope Requests (Do NOT submit to NCH)

Requests are out of scope and should NOT be submitted to NCH if they meet ANY of the following:

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 testing and lab services: Genetic lab testing and laboratory services

What Providers Must Do

Prior Authorization

Submit oncology medication regimen to Evolent/NCH

All participating providers must submit requests for listed oncology medications/supportive agents to Evolent (formerly New Century Health) for review prior to dispensing or administration; submit the entire oncology regimen to avoid denial.

Submit entire oncology regimen — omissions may result in denial

Prior Authorization

Submission methods and contact

Requests can be submitted via NCH web portal or by phone; non-participating providers should use the plan fax (new fax effective 10/1/2023).

Portal: mynewcenturyhealth.com
Phone: 1-888-999-7713 option 1
Non-participating provider fax: 1-844-235-5090 (effective 10/1/2023)

Documentation Required

Include entire regimen

Providers must include the entire oncology regimen when submitting to Evolent; omissions may result in denials.

Operational tip: To prevent denials, submit the full regimen including supportive agents and all scheduled therapies

Codes Requiring Centralized Review

Medically-administered oncology medications and supportive agents requiring NCH review (medical or pharmacy benefit)HCPCS|J-codes|C-codes|Q-codesCovered

C9142	BEVACIZUMAB-MALY
C9146	MIRVETUXIMAB SORAVTANSINE-GYNX / LEVOLEUCOVORIN INJ / J0641 mapping
C9147	TREMELIMUMAB-ACTL INJECTION / J0642
C9148	TECLISTAMAB-CQYV INJECTION / J0881
C9155	EPCORITAMAB-BYSP / J0885
C9163	INJ TALQUETAMAB-TGVS / J0888
C9165	INJ ELRANATAMAB-BCMM / J0893
C9293	GLUCARPIDASE / J0894
J0185	APREPITANT INJ / J0896 / LUSPATERCEPT-AAMT mapping
J0207	AMIFOSTINE INJ / J0897

1–10 of 215

1/22

Oral oncology medications requiring NCH review (pharmacy benefit only)NDC|CPT|J-codes mapped as J8999 for unspecified oral oncologyCovered

J8999	UNCLASSIFIED ORAL ONCOLOGY AGENTS (used as placeholder for numerous listed oral agents)
J7520	SIROLIMUS ORAL
J7527	(listed)
J8501	APREPITANT ORAL (5 MG / suspension / TRIPAK mappings)
J8530	CYCLOPHOSPHAMIDE ORAL mapping
J8565	GEFITINIB mapping
J8655	NETUPITANT/ PALONOSETRON ORAL mapping
J8670	ROLAPITANT ORAL mapping
J8999	Extensive list of oral targeted and hormonal agents (abemaciclib; abiraterone; afatinib; alectinib; alpelisib; anastrozole; apalutamide; axitinib; azacitidine oral; bicalutamide; bosutinib; brigatinib; cabozantinib; capivasertib; crizotinib; dabrafenib; dacomitinib; darolutamide; dasatinib; decitabine cedazuridine oral; duvelisib; enasidenib; encorafenib; entrectinib; erdafitinib; erlotinib; ever many others listed in the document)

Some listed HCPCS/J/Codes are represented on the code lists as mapped to J8999, J9999 or other unclassified/miscellaneous codes, and the policy contains numerous duplicate or alternate mappings for the same agents. Billing teams should refer to the full code lists in this policy for the exact code-to-agent mappings and to confirm which mapping applies.

Please note the code list updates were made Effective 1/1/2024; use the policy’s published lists to determine applicability by date and benefit.

Operational Notes & Contacts

Operationally, this policy reflects a centralized utilization review vendor relationship with Evolent (formerly New Century Health/NCH); all participating providers must submit requests for listed oncology medications/supportive agents to NCH prior to dispensing or administration. The policy also delineates out-of-scope items that should NOT be submitted (for example antibiotics, bone marrow/stem cell transplants and CAR-T, inpatient drugs, equipment requests, and others listed).

Remember to submit the entire oncology regimen to Evolent/NCH (omitting items may result in denial) and use the NCH web portal, phone number, or the non-participating provider fax for submission as noted in the policy.

Quick contact

VendorEvolent (formerly NCH)

Portal URLmynewcenturyhealth.com

Phone1-888-999-7713 (option 1)

Fax for non-participating providers1-844-235-5090 (effective 10/1/2023)

Effective date2024-01-01

Policy statusCURRENT