CurrentFidelis CarePolicy N/A

Oncology medications prior authorization and biosimilar preferences

Governs prior authorization review processes for oncology medications and supportive agents for Fidelis Care Essential Plan and Qualified Health Plan members, including provider submission requirements and a list of HCPCS/J-codes requiring prior authorization; affects providers dispensing or administering oncology drugs.

Policy Summary

PayerFidelis Care

PolicyOncology medications prior authorization and biosimilar preferences

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to New Century Health via my.newcenturyhealth.com or by calling 1-888-999-7713 (option 1); include all drugs even if some might not otherwise require prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~300+HCPCS/J/Q codes listed

18+Age scope

Portal & phoneSubmission routes

MultipleBiosimilar preferences

Coverage and Prior Authorization Criteria

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Prior authorization criteria

Covered when ALL of the following are met

Regimen submission: The provider submits the entire oncology regimen to New Century Health (NCH) for review via the NCH web portal (my.newcenturyhealth.com) or by calling 1-888-999-7713 (option 1) prior to dispensing or administration.

Any omissions may result in a denial.

Member/site scope: The request is for an oncology medication or supportive agent for a member subject to NCH review (drugs dispensed at a pharmacy or administered in a physician’s office, outpatient hospital, or ambulatory/infusion setting).Members age 18 and older (pediatric inclusion begins 7/1/2022)

Clinical trials may be sent to NCH for review effective 7/1/2022.

Drug listed: The requested drug/service is one of the HCPCS/J-/Q-codes listed in the policy as requiring prior authorization.

See the policy coding section for the full list of HCPCS/J- and Q-codes that require prior authorization.

Requests for the items listed as out-of-scope should not be submitted to New Century Health for prior authorization. Out-of-scope examples include antibiotics; bone marrow or stem cell transplants and CAR‑T cell therapy; Cablivi; controlled substances; equipment requests (e.g., 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.

HCPCS / J- / Q-code Listings

Listed HCPCS examples (partial)HCPCSCovered

C9095	TEBENTAFUSP-TEBN INJ.
C9142	BEVACIZUMAB-MALY INJ.
J0185	APREPITANT INJECTION
J0207	AMIFOSTINE 500 MG INJ
J0594	BUSULFAN 1 MG INJ
J0641	LEVOLEUCOVORIN CALCIUM INJECTION
J0642	LEVOLEUCOVORIN

HCPCS/J- and Q-codes requiring prior authorization (selection)HCPCSCovered

J0897	DENOSUMAB XGEVA INJECTION
J1442	FILGRASTIM G-CSF 1 MCG INJECTION
J1447	TBO-FILGRASTIM
J2506	PEGFILGRASTIM DELIVERY KIT (ON-BODY INJECTOR)
J8999	UNSPECIFIED ORAL ANTINEOPLASTIC
J9000	DOXORUBICIN HCL INJECTION
J9015	INJECTION ALDESLEUKIN
J9021	ASPARAGINASE ERWINIA CHRYSANTHEMI RECOMBINANT
J9030	BCG LIVE INTRAVESICAL VAC
J9040	BLINATUMOMAB

1–10 of 21

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Provider Submission Requirements and Actions

Prior Authorization

Prior authorization required for listed oncology HCPCS/J-codes

Prior authorization is required for the HCPCS/J- and Q-codes listed in this policy; providers must submit prior authorization requests for these drugs to New Century Health (NCH) before dispensing or administration.

Codes include (selection): J0897, J1442, J2506, J8999, J9000, J9118, J9145, J9271, J9311, Q5101, Q5112, Q5126 (see coding module for full list).

Note

Biosimilar preference for select oncology agents

The policy identifies preferred biosimilar agents for specific reference biologics and implies payer preference for using those biosimilars for oncology-related indications.

Trastuzumab preferred biosimilars: Kanjinti, Ogivri, Trazimera.
Bevacizumab preferred biosimilars: Mvasi, Zirabev.
Rituximab preferred biosimilars: Ruxience, Truxima, Riabni.

Prior Authorization

Submit entire regimen to New Century Health via portal or phone

Submit the entire oncology regimen to New Century Health via the NCH web portal (my.newcenturyhealth.com) or by calling 1-888-999-7713 (option 1); include all drugs in the regimen even if some might not otherwise require prior authorization.

Include every agent in the regimen when submitting to NCH.
Use the web portal at my.newcenturyhealth.com or phone 1-888-999-7713, option 1.

Denial Risk

Omission of regimen elements may cause denial

Failure to submit the entire oncology regimen to New Century Health, including all agents, may result in a denial of the request.

The policy note states: 'Any omissions may result in a denial.'

Background and Scope

New Century Health (NCH) performs clinical review of oncology medications and supportive agents for members; providers must submit the entire oncology regimen to NCH for review via the NCH portal or by phone. Any omissions may result in a denial. The centralized review includes adult members and pediatric inclusion began effective 7/1/2022, and it also captures biosimilar preferences for commonly used oncology agents.

Definitions and Key Terms

NCH — New Century Health definition

Full nameNew Century Health

AbbreviationNCH

RolePerforms clinical review of oncology medications and supportive agents prior to dispensing or administration

Population scopeMembers 18 and older (pediatric inclusion beginning 7/1/2022)

Submission routesNCH web portal (my.newcenturyhealth.com) or phone: 1-888-999-7713 (option 1)

Site-of-care coverageReviews required before drugs are dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory/infusion setting

Site-of-Care Prior Authorization Requirements

Prior Authorization

Prior authorization required across sites of care

Prior authorization review by New Century Health is required before oncology drugs are dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or infusion/ambulatory setting.

This requirement applies to pharmacy, office, hospital outpatient, and infusion center settings for members 18 and older (pediatric inclusion effective 7/1/2022).

Biosimilar Agent Preferences

Billing Rule

Trastuzumab preferred biosimilars identified

Preferred biosimilar agents are listed for trastuzumab; providers should present these biosimilars as the payer's preferred choices for oncology indications.

Preferred trastuzumab biosimilars: Kanjinti, Ogivri, Trazimera.
Several Q-codes for trastuzumab biosimilars are listed (e.g., Q5112, Q5113, Q5114, Q5116).

Billing Rule

Bevacizumab preferred biosimilars identified

Preferred biosimilar agents are listed for bevacizumab; providers should use these biosimilars consistent with payer preference for oncology indications.

Preferred bevacizumab biosimilars: Mvasi, Zirabev.
Bevacizumab biosimilar Q-codes included (e.g., Q5126, Q5118).

Billing Rule

Rituximab preferred biosimilars identified

Preferred biosimilar agents are listed for rituximab; providers should follow these preferences for oncology-related uses.

Preferred rituximab biosimilars: Ruxience, Truxima, Riabni.
Multiple Q-code rituximab biosimilars are listed (e.g., Q5115, Q5119, Q5123).

Billing Rule

Filgrastim preference differs by benefit type

Preferred filgrastim differs by benefit: Nivestym is the preferred agent under the pharmacy benefit, while Zarxio is preferred under the medical benefit.

Pharmacy benefit preferred: Nivestym (also listed as Q5110).
Medical benefit preferred: Zarxio (listed in the narrative as medical benefit).

Billing Rule

Pegfilgrastim preferences differ by pharmacy vs medical benefit

Preferred pegfilgrastim agents are distinguished by pharmacy versus medical benefit; providers should select agents according to the applicable benefit.

Pharmacy benefit preferred: Neulasta, Neulasta Onpro, Udenyca (also represented by certain Q-codes).
Medical benefit preferred: Fulphila, Udenyca, Ziextenzo, Nyvepria.

Policy Summary

PayerFidelis Care

PolicyOncology medications prior authorization and biosimilar preferences

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

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