Oncology medications and supportive agents prior authorization
Customize your policy alerts
Sign up for all Fidelis Care policy alerts
Know when Fidelis Care releases new policies or updates existing guidance.
Monitor payer policy activity
Defines Evolent review and prior authorization requirements for oncology medications and supportive agents for Fidelis Care Essential Plan and Qualified Health Plans (members 18+; pediatric membership added 7/1/2022). Applies to dispensing at pharmacy or administration in physician office, outpatient hospital, or ambulatory settings.
No material clinical or coverage changes in this revision.
Coverage Preconditions and Scope
Prior authorization coverage preconditions
Covered when ALL of the following are met
Pediatric membership inclusion effective 7/1/2022; clinical trials may be submitted for review effective 7/1/2022.
The following request types are out of scope for submission to Evolent and should not be sent for prior authorization or review: Antibiotics; Bone marrow/stem cell transplants and CAR-T cell therapy; Cablivi; Controlled substances; Equipment requests (infusion pumps); Genetic laboratory testing and laboratory services; Hemophilia drugs; Immune globulins; Inpatient drug requests; Iron preparations; Pain medications; Radiopharmaceuticals; Surgeries/surgical procedures; and Sickle cell diagnoses.
| Requirement | Details |
|---|---|
| Requirement to submit full regimen | |
| All oncology regimens composed of agents listed in this document must have the entire regimen submitted to Evolent for review. Omission of any drug in the oncology regimen submission may result in a denial. |
HCPCS / J- / Q-code Listings
| J9357 | TRASTUZUMAB/HYALURONIDASE-OYSK |
| J9358 | INJECTION VALRUBICIN INTRAVESICAL |
| J9359 | FAM-TRASTUZUMAB DERUXTECAN-NXKI |
| J9360 | LONCASTUXIMAB TESIRINE-LPYL |
| J9361 | INJECTION VINBLASTINE SULFATE 1 MG |
| J9370 | INJECTION, EFBEMALENOGRASTIM ALFAVUXW |
| J9371 | VINCRISTINE SULFATE 1 MG |
| J9380 | VINCRISTINE LIPOSOMAL |
| J9382 | TECLISTAMAB-CQYV INJECTION (TECVAYLI) |
| J9390 | ZENOCUTUZUMAB-ZBCO (BIZENGRI) |
| J9999 | Multiple entries for miscellaneous/injectable drugs (e.g., BEXAROTENE 1% TOPICAL GEL; DOCETAXEL (DOCIVYX); FLUOROURACIL topical formulations; IMIQUIMOD; MELPHALAN INJ; PEGINTERFERON, etc.) |
| Q0155 | DRONABINL ORAL (SYNDROS) |
| Q2017 | TENIPOSIDE 50 MG |
| Q2043 | |
| Q2050 | SIPULEUCEL-T AUTO CD5+ |
| Q5101 | LIPOSOMAL DOXORUBICIN |
| Q5106 | FILGRASTIM-SNDZ |
| Q5107 | EPOETIN ALFA-EPBX (RETACRIT BIOSIMILAR) |
| Q5108 | BEVACIZUMAB - AWWB |
| Q5110 | PEGFILGRASTIM-JMDB |
| Q5111 | FILGRASTIM-AAFI (NIVESTYM BIOSIMILAR) |
Authorization, Submission & Billing Requirements
How to submit and required content
Oncology drugs and supportive agents listed in this policy require prior authorization through Evolent. Submit requests via Evolent's web portal (my.newcenturyhealth.com) or by phone at 1-888-999-7713, option 1. Include the full oncology regimen (all agents, supportive medications, and exact dosing) when you submit; omission of any drug in the regimen may result in a denial.
- Submit the entire oncology regimen regardless of individual drug PA status — omissions may result in denial.
- Submission methods: Evolent web portal (my.newcenturyhealth.com) or phone 1-888-999-7713, option 1.
- Required content: member demographics, clinical indication/diagnosis, full regimen including all agents (drug names and doses), treatment start date, prior therapies, relevant labs/imaging, and supporting clinical notes.
Code mismatch denial risk
Billing must use the precise HCPCS/J/Q code that corresponds to the administered drug. If the claim is billed with a HCPCS code that does not match the drug listed on the prior authorization (or with an unlisted/non-specific code), the claim may be denied.
- Always submit the exact HCPCS/J/Q code for the administered product on both the prior authorization request and the claim.
- If a product is reported under a generic or unlisted HCPCS (e.g., J9999) without clear linkage to the prior auth documentation, expect increased denial risk.
Provider actions & billing requirements
Providers must ensure regimen completeness and coding accuracy when requesting authorization and when billing. Prior authorization applies to the oncology HCPCS/J/Q codes listed in this policy; verify the code(s) submitted for authorization match the code(s) billed.
- Regimen completeness: include every drug in the treatment regimen on the PA submission — missing agents can cause claim or PA denial.
- Coding documentation: include the precise HCPCS/J/Q code for each administered drug on the PA request and on the claim.
- Prior authorization requirement: listed oncology drugs/supportive agents are subject to Evolent prior auth for members (effective 2022-07-01).
Policy Background and Scope Notes
This policy defines the operational prior authorization and review processes for oncology medications and supportive agents administered in outpatient settings or dispensed at pharmacy for Fidelis Care members. Providers must submit the entire oncology regimen to Evolent for review; omission of any drug in the regimen may result in denial. The review process is limited to administrative and authorization determinations for the listed agents and does not provide disease-specific clinical treatment guidance.
Prior authorization and review are not intended to cover items explicitly listed as out of scope (see out-of-scope list). For drugs that are included in the document, providers must follow the submission procedures and supply the complete regimen and the precise HCPCS/J/Q codes for the agents to support authorization and claims processing.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.