Oncology medications and supportive agents prior authorization and review
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Defines which oncology medications and supportive agents require review by Evolent/New Century Health (NCH) for Fidelis Care (Wellcare) Medicare members, and lists HCPCS/J-codes and pharmacy agents in scope and out-of-scope items. Affects participating providers dispensing or administering oncology drugs in outpatient, office, or pharmacy settings.
No material clinical or coverage changes in this revision.
Coverage Criteria
Prior review required
Covered when ALL of the following are met
Applies to members of all ages and includes medical- and pharmacy-benefit agents as indicated; clinical trials may be submitted
Do NOT submit the following to New Century Health (NCH) for review: Antibiotics; Bone marrow, stem cell transplants, and CAR‑T cell therapy; controlled substances (e.g., morphine); equipment requests (infusion pumps); genetic laboratory testing and laboratory services; hemophilia drugs; inpatient drug requests; inpatient radiation and chemotherapy treatments; iron preparations; radiopharmaceuticals; surgeries/surgical procedures; sickle cell diagnoses and therapies; and immune globulins.
Coding and Billing (HCPCS, J‑codes, Pharmacy)
| J1434 | FOSAPREPITANT (FOCINVEZ) |
| J1442 | FILGRASTIM G-CSF 1 MCG INJ |
| J1447 | TBO-FILGRASTIM |
| J1448 | TRILACICLIB INJ |
| J1449 | EFLAPEGRASTIM-XNST INJECTION |
| J1453 | FOSAPREPITANT INJ |
| J1454 | FOSNETUPITANT/PALONOSETRON |
| J1456 | FOSAPREPITANT INJ |
| J1627 | GRANISETRON HCL ER INJ |
| J1930 | LANREOTIDE |
| C9142 | BEVACIZUMAB-MALY |
| C9146 | MIRVETUXIMAB SORAVTANSINE-GYNX |
| C9147 | TREMELIMUMAB-ACTL INJECTION |
| C9148 | TECLISTAMAB-CQYV INJECTION |
| C9155 | EPCORITAMAB-BYSP |
| C9163 | INJ TALQUETAMAB-TGVS |
| C9165 | INJ ELRANATAMAB-BCMM |
| C9293 | GLUCARPIDASE |
Provider Actions and Requirements
Prior Authorization Required
Oncology medications and supportive agents (medical or pharmacy benefit) require review by Evolent (formerly New Century Health, NCH) for participating providers prior to dispensing or administration. Submit the entire oncology regimen to Evolent/NCH — omissions may result in a denial. Requests may be submitted via the NCH web portal (my.newcenturyhealth.com) or by phone at 1-888-999-7713, option 1. Non‑participating providers must submit requests to the plan via fax: 1-844-235-5090 (formerly 1-877-882-5892). Clinical trial medications may also be submitted for review.
- Submit the entire oncology regimen to Evolent/NCH; partial regimen submissions may be denied.
- Participating providers: use NCH web portal (my.newcenturyhealth.com) or call 1-888-999-7713, option 1.
- Non‑participating providers: submit to the plan via fax 1-844-235-5090.
Scope and Preferred Agents
The following lists summarize scope and preferred biosimilars that are managed via Evolent/NCH review. Do NOT submit the items listed as out-of-scope to NCH (e.g., inpatient drug requests, surgeries, stem cell transplants, CAR-T, genetic testing, hemophilia drugs, controlled substances, equipment requests, radiopharmaceuticals, immune globulins, sickle cell therapies). Preferred biosimilar agents for certain oncology-related indications are identified (providers should still submit requests for the preferred agent to NCH for clinical review).
- Out of scope (do NOT submit to NCH): Antibiotics; Bone marrow/stem cell transplants; CAR-T cell therapy; Controlled substances; Equipment (infusion pumps); Genetic lab testing; Hemophilia drugs; Inpatient drug requests; Inpatient radiation/chemotherapy; Iron preparations; Radiopharmaceuticals; Surgeries; Sickle cell diagnoses/therapies; Immune globulins.
- Preferred biosimilars (submit preferred agent to NCH for review): Erythropoiesis-stimulating agents (Medical: Retacrit; Pharmacy: Procrit), Trastuzumab (Medical: Trazimera; Pharmacy: Herceptin and biosimilars), Bevacizumab (Medical: Mvasi, Zirabev; Pharmacy: Avastin and biosimilars), Hematopoietic agents (Zarxio), Rituximab (Medical: Ruxience, Truxima; Pharmacy: Riabni, Rituxan, others), Bone agents and others as specified in the policy.
Complete Regimen Submission Required
All oncology regimen components (all agents, supportive drugs, and related administration codes) must be included in the submission to NCH. Failure to include any part of the regimen when submitting to Evolent/NCH may result in a denial of authorization.
- Include the entire regimen (all agents and supportive medications) in a single submission to Evolent/NCH.
- Clinical rationale and indication should be provided to establish medical necessity for each agent.
Pharmacy Benefit Review
A secondary list identifies oncology medications/supportive agents that require NCH review when provided via the pharmacy benefit only. Check the plan's code lists (HCPCS/CPT/NDC) and pharmacy benefit rules; if the drug is delivered via pharmacy and appears on the pharmacy-only list, submit to NCH for review.
- Drugs billed via pharmacy benefit that appear on the pharmacy-only list require NCH review prior to dispensing.
- Verify benefit pathway (medical vs pharmacy) and submit accordingly to NCH.
Biosimilar Preference Notice
Preferred biosimilar agents for certain oncology-related indications are listed in the policy. Providers should still send requests for the preferred agent to NCH for review and authorization.
- Examples include preferred agents for trastuzumab, bevacizumab, rituximab, erythropoiesis-stimulating agents, and hematopoietic agents as detailed in the policy lists.
Initial Therapy Criteria
Initial authorization
Initial coverage step
If provider is non-participating with NCH, submit prior authorization request to the plan via fax as specified in the policy
Step Therapy and Preferred Agents
| Drug class / agent(s) | Preferred biosimilar(s) / benefit assignment | Provider action |
|---|---|---|
| Erythropoiesis-stimulating agents | Medical benefit: Retacrit (if unavailable due to shortage: Epogen); Pharmacy benefit: Procrit | Submit request for the preferred agent to New Century Health (NCH) for review prior to dispensing or administration |
| Trastuzumab (HER2-directed therapies) | Medical benefit: Trazimera; Pharmacy benefit: Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera | Providers should send requests for the preferred trastuzumab product/biosimilar to NCH for review |
| Bevacizumab (anti‑VEGF) | Medical benefit: Mvasi, Zirabev; Pharmacy benefit: Avastin, Mvasi, Zirabev | Submit preferred bevacizumab product (including biosimilars) to NCH for review |
| Hematopoietic agents / filgrastim biosimilars | Medical & Pharmacy benefit: Zarxio | Send request for Zarxio (or other listed hematopoietic agent) to NCH for review |
| Rituximab | Medical benefit: Ruxience, Truxima; Pharmacy benefit: Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima | Providers must submit requests for the preferred rituximab product to NCH for review |
Site of Care Requirements
Prior review required for office administration
Prior review by NCH is required before administration of listed oncology medications and supportive agents in physician offices, outpatient hospitals, or ambulatory settings.
Prior review required for infusion center administration
Prior review by NCH is required before administration of listed oncology medications and supportive agents at infusion centers (physician office, outpatient hospital, ambulatory settings).
Pharmacy benefit agents still require NCH review
Certain listed agents are pharmacy benefit only but still require New Century Health review prior to dispensing; providers must submit these pharmacy‑only agents to NCH as indicated in the pharmacy list.
Biosimilar Preferences and Examples
Erythropoiesis‑stimulating agent benefit assignment examples
Benefit assignment example: for erythropoiesis‑stimulating agents Retacrit is the medical‑benefit example (with Epogen noted if Retacrit is unavailable due to shortage); Procrit is listed as the pharmacy benefit product.
Trastuzumab reference products and pharmacy examples
Trastuzumab benefit assignment examples: Trazimera is listed as the medical benefit reference product; Herceptin and listed trastuzumab biosimilars are noted for the pharmacy benefit.
Background
Oncology medications and supportive agents include a broad range of infused and oral anticancer drugs, hematopoietic growth factors, antiemetics, and supportive biologics. This policy identifies agents that require review by Evolent/New Century Health (NCH) to confirm indication appropriateness and to determine benefit routing (medical vs. pharmacy). Preferred biosimilar agents are listed for certain classes to guide benefit assignment, but providers must still submit requests for the preferred agent to NCH for review.
Definitions
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