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CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents prior authorization (coverage criteria)

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Governance of prior review and prior authorization requirements for oncology medications and supportive agents for Fidelis Care Medicaid Managed Care & HealthierLife members (adults; pediatric inclusion noted). Applies to dispensing at pharmacy and administration in physician office, outpatient hospital, or ambulatory settings.

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior authorization (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent via the portal or by calling 1-888-999-7713 to obtain prior authorization before dispensing or administration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1+ listsHCPCS/J-code lists

5+Distinct J-codes listed

20+Q-codes / biosimilars

AdultsMember population

ListedOut-of-scope categories

NCApplicable state

Coverage Criteria & Scope

Authorization requirement

Covered when ALL of the following are met

Evolent review and submission: Oncology medications and supportive agents require review by Evolent before being dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting for members 18 and older; requests must be submitted via Evolent's web portal (my.newcenturyhealth.com) or by calling 1-888-999-7713, option 1.

Pediatric members will be included starting 7/1/2022

Complete regimen submission: The entire oncology regimen must be submitted to Evolent; omissions of regimen elements may result in denial.

Scope exclusions: Requests for items explicitly listed as out-of-scope must NOT be submitted to Evolent (examples include: antibiotics; bone marrow/stem cell transplants; CAR-T cell therapy; Cablivi; controlled substances; infusion pumps/equipment requests; genetic lab testing and laboratory services; hemophilia drugs; immune globulins; inpatient drug requests; iron preparations; pain medications; radiopharmaceuticals; surgeries/surgical procedures; sickle cell diagnoses; Zoladex).

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior authorization (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent via the portal or by calling 1-888-999-7713 to obtain prior authorization before dispensing or administration.

SourceLink

On This Page

Code Lists and Mappings

Prior authorization required HCPCS/J-codes list (documented groups)HCPCSCovered

C9293	GLUCARPIDASE
J0897
J0185	APREPITANT INJECTION
J0207	INJECTION AMIFOSTINE 500 MG
J0208	SODIUM THIOSULFATE
J1323	ELRANATAMAB-BCMM
J0594	INJECTION BUSULFAN 1 MG
J0641	LEVOLEUCOVORIN CALCIUM INJECTION
J0642	LEVOLEUCOVORIN
J0870	IMETELSTAT (RYTELO)

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Listed J-codesHCPCS

J9319	FULVESTRANT (FRESNIUS KABI) / POWDER mappings shown
J9320	INJECTION STREPTOZOCIN 1 G / INJECTION FULVESTRANT 25 MG mappings shown
J9321	INJ EPCORITAMAB-BYSP / J9400 / INJECTION, ZIV-AFLIBERCEPT
J9322	PEMETREXED (BLUEPOINT) INJECTION / J9600 / INJECTION PORFIMER SODIUM 75 MG
J9323	PEMETREXED INJECTION, NOT / J9601 / LINVOSELTAMAB-GCPT INJ

Listed J9999 and Q-codes / biosimilarsHCPCS

J9999	Multiple product mappings listed under J9999 to specific products and Q-codes (e.g., BEVACIZUMAB-NWGD (JOBEVNE), BEXAROTENE, DOCETAXEL variants, FILGRASTIM formulations, DENOSUMAB variants, etc.)
Q5126	BEVACIZUMAB-MALY INJ
Q5127	PEGFILGRASTIM-FPGK INJ (STIMUFEND)
Q5129	BEVACIZUMAB - ADCD INJ (VEGZELMA)
Q5130	PEGFILGRASTIM-PBBK INJ (FYLNETRA)
Q5136	DENOSUMAB-BBDZ (JUBBONTI, WYOST)
Q5146	TRASTUZUMAB-STRF (HERCESSI)
Q5148	FILGRASTIM-TXID INJ (NYPOZI)
Q5157	DENOSUMAB0-BMWO (STOBOCLO/OSENVELT)
Q5158	DENOSUMAB-BNHT (BOMYNTRA/CONEXXENCE)

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Provider Requirements & Submission Instructions

Prior Authorization

Evolent review (prior authorization) required

Oncology medications and supportive agents require review by Evolent (prior authorization) before being dispensed or administered for members 18 and older.

Billing Rule

Use mapped HCPCS J- and Q-codes for requests

Claims and authorization requests must use the mapped J- and Q-codes shown for the corresponding drug products when requesting coverage or submitting claims.

Note

Submit entire regimen

Submit the entire oncology regimen to Evolent regardless of prior authorization status.

Note

Do not submit out-of-scope items

Do not submit out-of-scope items to Evolent (e.g., antibiotics, CAR-T, inpatient drugs, infusion pumps, genetic testing).

Examples listed as out of scope: Antibiotics; Bone Marrow/Stem Cell Transplants; CAR-T Cell Therapy; Equipment Requests (infusion pumps); Genetic Lab Testing and Laboratory Services; Inpatient Drug Requests; Radiopharmaceuticals; and others in the list.

Documentation Required

How to submit regimen

Submit the entire oncology regimen to Evolent via the web portal (my.newcenturyhealth.com) or by calling 1-888-999-7713, option 1.

Portal: my.newcenturyhealth.com
Phone: 1-888-999-7713, option 1

Billing Rule

Use listed code mappings when submitting claims

When billing, reference the listed J- and Q-code mappings provided in the policy for the named injectable drugs and biosimilars.

Denial Risk

Complete regimen required (risk of denial)

Omitting elements of the entire oncology regimen when submitting to Evolent may result in a denial.

Denial Risk

Coding mismatch may cause claim denial

Incorrect HCPCS/J-code or Q-code mapping on a claim may trigger denial or miscoding because exact code-to-product associations are provided.

Key Terms & Billing Codes

HCPCS J- and Q-code mappings — definitions and billing guidance

DefinitionQ-codes correspond to specific biosimilar or biologic product identifiers used for billing; they map individual biosimilar products (e.g., Q5126, Q5127, Q5129, Q5130, Q5136, Q5146, Q5148, Q5157, Q5158, Q5159, Q5160) to originator or biosimilar drug names.

DefinitionJ-codes are HCPCS procedure codes used to report drug administration and injectable agents (e.g., J9999 is used with specific product mappings shown under J9999 entries).

Actionable billing noteWhen submitting claims or authorization requests, use the listed J- and Q-code mappings that correspond to the specific biosimilar or biologic product (example mappings shown: J9999 entries paired with Q-codes like Q5126, Q5127, Q5129, Q5130, Q5136).

Example mappingJ9999 mapping examples in this policy include BEVACIZUMAB-NWGD mapped to Q5160 and BEVACIZUMAB-MALY mapped to Q5126.

Example mappingPEGFILGRASTIM biosimilars are listed with Q-codes such as Q5127 (PEGFILGRASTIM-FPGK/STIMUFEND) and Q5130 (PEGFILGRASTIM-PBBK/FYLNETRA).