Fidelis Care oncology prior auth Policy Update | OpenPayer
CurrentFidelis CarePolicy N/A
Oncology medications and supportive agents prior authorization
Defines Evolent review/authorization requirements for oncology drugs and supportive agents dispensed in pharmacy or administered in outpatient/ambulatory settings for Fidelis Care members; applies initially to adults and expanding to pediatric membership starting 7/1/2022.
Policy Summary
PayerFidelis Care
PolicyOncology medications and supportive agents prior authorization
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJul 1, 2022
Next Review DateN/A
Key ActionSubmit the entire oncology regimen to Evolent via the web portal or by phone to avoid denial.
No material clinical or coverage changes in this revision.
18+member age scope
Portal & phonesubmission methods
Multiplelisted codes
Regimen-levelregimen requirement
~80+drug entries listed
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Coverage Criteria
Prior authorization and regimen submission
Covered when ALL of the following are met
Evolent review required: The oncology medication or supportive agent is reviewed by Evolent prior to dispensing or administration for applicable members.
Includes pharmacy dispensing and administration in physician office, outpatient hospital, or ambulatory setting; pediatric membership included starting 7/1/2022; clinical trials may be sent for review effective 7/1/2022.
Regimen submission: The provider submits the entire oncology regimen to Evolent; omission of any regimen component may result in denial.
Submit requests via Evolent's web portal (mynewcenturyhealth.com) or by calling 1-888-999-7713, option 1.
The following requests are out of scope and should NOT be submitted to Evolent: 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.
Oncology medications and supportive agents require review by Evolent prior to dispensing or administration for members (effective 2022-07-01). Requests must be submitted via Evolent's web portal at mynewcenturyhealth.com or by phone at 1-888-999-7713, option 1. Clinical trials may be submitted for review effective 7/1/2022. Submit the entire oncology regimen to Evolent — omitting drugs from the regimen can result in a denial.
Prior authorization required for oncology medications and supportive agents for members age 18+ (pediatrics included starting 7/1/2022).
Submit requests via Evolent Web portal (mynewcenturyhealth.com) or phone: 1-888-999-7713, option 1.
Submit the entire oncology regimen; omissions may lead to denial.
Note
Requests Out of Scope
Do not submit the following to Evolent (out of scope): 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
HCPCS Code Listing and Denial Triggers
The following HCPCS (J- and Q-) codes and associated injectable oncology/supportive care drugs require authorization. Providers must include all drugs in the submitted regimen to avoid denial. This list includes, but may not be limited to, the codes shown below.
Failure to include all agents in the submitted regimen (including supportive agents listed above) may result in denial of the authorization request. If a drug is out of scope (see 'Requests Out of Scope'), do not submit it to Evolent.
Definitions
inv-15: Entire oncology regimen — requirement to submit all agents in a patient's oncology treatment regimen together
Action RequiredSubmit the ENTIRE oncology regimen to Evolent regardless of individual prior authorization requirements.
Consequence of OmissionOmission of any regimen component may result in a denial by Evolent.
Submission MethodsSubmit via Evolent web portal (mynewcenturyhealth.com) or by phone as specified in the policy.
Scope NoteRequirement applies to oncology medications and supportive agents dispensed at pharmacy or administered in physician office, outpatient hospital, or ambulatory settings (pediatric membership included starting 7/1/2022).
inv-16: Billing codes for injectable drugs and biologics — HCPCS J- and Q-codes as listed
Code TypesBilling codes listed are HCPCS J- and Q-codes for injectable oncology and supportive care drugs and biosimilars.
Example J-codesIncludes J9331, J9340, J9345, J9347, J9348, J9349, J9350, J9351, J9352, J9353, J9354, J9355, J9356, J9357, J9358, J9359, J9360, J9361 (as shown in the J-code lists).
Reference Examples in DocumentSpecific mappings and drug names associated with codes appear in the J-code lists (chunks 18–19) and Q-code/biosimilar list (chunk 20).
Background
This policy lists oncology medications and supportive care agents (including injectable biologics and growth factors) and requires Evolent review prior to dispensing or administration. Authorization is required before dispensing at a pharmacy or before administration in a physician office, infusion/ambulatory center, or hospital outpatient setting. Providers must submit the entire oncology regimen to Evolent — omission of any regimen component may result in denial. Requests must be submitted via the Evolent web portal or by phone as specified in the policy.
Site of Care
Prior Authorization
Authorization required at pharmacy and administration sites
Authorization is required before dispensing at a pharmacy or before administration in a physician office, infusion center, or hospital outpatient/ambulatory setting.
Do not dispense or administer listed agents without prior Evolent review.
Biosimilar Notes
Note
Filgrastim (Q-code biosimilar entries) — no preference specified
Filgrastim and its biosimilar entries are listed in the Q-code section; the excerpt lists filgrastim biosimilars but does not specify a formulary preference or substitution rule in this section.