CurrentFidelis CarePolicy N/A

Oncology Services - Essential Plan and Metal-Level Products/QHP

Defines requirement for Evolent review/prior authorization of oncology medications and supportive agents for Essential Plan and Qualified Health Plans (members 18+, pediatric added 7/1/2022), lists HCPCS/J-codes and other billing codes requiring prior authorization, and lists items out-of-scope that should not be submitted.

Policy Summary

PayerFidelis Care

PolicyOncology Services - Essential Plan and Metal-Level Products/QHP

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests for oncology medications and supportive agents to Evolent before dispensing or administration via my.newcenturyhealth.com or 1-888-999-7713 (option 1), including the entire oncology regimen.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes.

200+Listed Codes/Reagents

1Prior Authorization Vendor

7/1/2022Pediatric inclusion effective date

Coverage Summary

This policy requires that Evolent (New Century Health) review and authorize oncology medications and supportive agents for Essential Plan and Qualified Health Plan members; it applies to members 18 and older with pediatric membership included beginning 2022-07-01. Requests must be submitted to Evolent using their portal or phone, and providers must submit the entire oncology regimen (complete regimen submission is required) to avoid potential denials.

Key facts

Listed Codes/Reagents200+

Prior Authorization VendorEvolent (New Century Health)

Pediatric inclusion effective date2022-07-01

scope_summaryRequires Evolent review/prior authorization of oncology medications and supportive agents for Essential Plan and Qualified Health Plans; lists HCPCS/J/C/Q codes requiring prior authorization and items out-of-scope that should not be submitted.

statusCURRENT

Prior Authorization and Scope Criteria

General Prior Authorization Requirement

Covered when ALL of the following are met:

Requests for oncology medications and supportive agents are reviewed by Evolent prior to dispensing or administration for members aged 18 and older (pediatric membership included effective 2022-07-01).

Clinical trial–related oncology medication requests may be submitted to Evolent for review effective 2022-07-01.

Submit the entire oncology regimen to Evolent for review (include all agents and supportive medications). Any omission of regimen components may result in a denial.

Out-of-Scope (Do Not Submit to Evolent)

The following items are out of scope for Evolent review. Do not submit these requests to Evolent:

any

- 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

Prior Authorization Required Drugs/Codes

The following HCPCS/CPT/J (and related) codes for drugs require prior authorization by Evolent. An extensive list of specific HCPCS/CPT/J/JJ/J8999 and other codes is enumerated in the Coding section of this policy; submitters should reference the full code list there when preparing a request.

Leaves: Extensive, enumerated list of HCPCS/CPT/J and other administration codes (including but not limited to J-codes, C-codes, and J8999 mappings) require prior authorization — see the Coding section for the complete code set.

Codes Requiring Prior Authorization / Out-of-Scope Codes

Prior authorization required - HCPCS / J-codes / C-codes / Q-codes / OthermixedCovered

C9293	GLUCARPIDASE
J0897	DENOSUMAB XGEVA INJECTION / DENOSUMAB PROLIA INJECTION (also referenced)
C9307	LINVOSELTAMAB-GCPT INJ
J1010	METHYLPREDNISOLONE ACETATE
C9308	CARBOPLATIN (AVYXA) INJ
J1246	INJECTION DINUTUXIMAB
J0185	APREPITANT INJECTION (also associated with other entries)
J1302	SUTIMLIMAB-JOME INJECTION
J0207	AMIFOSTINE 500 MG INJ
J1323	ELRANATAMAB-BCMM

1–10 of 139

1/14

Out-of-scope items (not to submit)mixedNot Covered

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

Provider Actions and Submission Instructions

Prior Authorization

Prior authorization required via Evolent

Submit prior authorization requests for oncology medications and supportive agents to Evolent before dispensing or administration. Use the Evolent web portal or phone to submit requests.

my.newcenturyhealth.com
Call 1-888-999-7713, option 1

Documentation Required

Submit entire oncology regimen

Submit the entire oncology regimen to Evolent. Omitting agents or supportive care from the submitted regimen may result in a denial.

include all agents and supportive care

Billing Rule

Do not submit out-of-scope items

Do not submit requests to Evolent for items that are out of scope. Examples include inpatient drug requests, transplants and CAR-T therapies, equipment requests (infusion pumps), radiopharmaceuticals, and other listed categories.

Antibiotics
Bone marrow / stem cell transplants and CAR-T cell therapy
Equipment requests (infusion pumps)
Inpatient drug requests
Radiopharmaceuticals
Surgeries / surgical procedures

Background

Background: Evolent (New Century Health) is the designated reviewer for oncology medications and supportive agents for Essential Plan and Qualified Health Plans; this policy centralizes prior authorization and clinical review decisions to Evolent. Operationally, centralized review means providers must obtain prior authorization from Evolent before dispensing or administering covered oncology drugs in outpatient settings (pharmacy, physician's office, outpatient hospital, or ambulatory settings) and must submit the full oncology regimen when requesting authorization; omissions or failure to submit prior authorization may result in denial. Do not submit items listed as out-of-scope (e.g., inpatient drugs, transplants/CAR-T, equipment, certain lab services, etc.) to Evolent.

Definitions

EvolentDesignated review organization (New Century Health) to process oncology medication prior authorization requests.