Oncology medications and supportive agents — Prior authorization / HCPCS/J/Q code mappings
Governs prior authorization and review requirements for oncology medications and supportive agents for Fidelis Care Medicaid Managed Care & HealthierLife members; affects providers dispensing or administering these drugs in pharmacy, physician office, outpatient hospital, or ambulatory settings for members aged 18+ (pediatrics added starting 7/1/2022).
No material clinical or coverage changes in this revision.
Coverage and Prior Authorization Criteria
Prior authorization / review criteria
Covered when ALL of the following are met
Includes pharmacy and outpatient/ambulatory administration for members 18+ (pediatrics added starting 7/1/2022)
Failure to submit the full regimen may result in denial
See the policy's HCPCS/J/Q code lists for the specific codes requiring prior authorization
The following requests are out of scope for Evolent review and should not be submitted: Antibiotics; Bone marrow/stem cell transplants; 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; Sickle cell diagnoses; Zoladex.
HCPCS / J / Q Codes and Mappings
| C9293 | GLUCARPIDASE |
| C9306 | TELISOTUZUMAB VEDOTIN-TLLV |
| J0185 | APREPITANT INJECTION |
| J0207 | INJECTION AMIFOSTINE 500 MG |
| J0208 | SODIUM THIOSULFATE |
| J0594 | INJECTION BUSULFAN 1 MG |
| J0641 | LEVOLEUCOVORIN CALCIUM INJECTION |
| J0642 | LEVOLEUCOVORIN |
| J0870 | IMETELSTAT (RYTELO) |
| J0881 | INJECTION DARBEPOETIN ALFA 1 MCG |
| J9328 | INJECTION TEMOZOLOMIDE 1 MG; also referenced with FLUOROURACIL 5% TOPICAL CREAM in same chunk |
| J9999 | Used as placeholder mapping to multiple products including IMIQUIMOD 5% TOPICAL CREAM; MECHLORETHAMINE 0.016% TOPICAL GEL; MELPHALAN INJ; PEGINTERFERON ALFA-2B (SYLATRON); PIRTOBRUTINIB (JAYPIRCA); TELISOTUZUMAB VEDOTIN-TLLV (EMRELIS); TIRBANIBULIN 1% TOPICAL OINTMENT; and others listed. |
| Q5146 | TRASTUZUMAB-STRF (HERCESSI) |
| Q5157 | DENOSUMAB0-BMWO |
| Q5158 | DENOSUMAB-BNHT |
| Q5159 | DENOSUMAB-DSSB (OSPOMYV/XBRYK) |
| Q5101 | FILGRASTIM-SNDZ |
| Q5106 | EPOETIN ALFA-EPBX (RETACRIT BIOSIMILAR) |
| Q5107 | BEVACIZUMAB - AWWB |
| Q5108 | PEGFILGRASTIM-JMDB |
| Q5110 | FILGRASTIM-AAFI (NIVESTYM BIOSIMILAR) |
| Q5111 | PEGFILGRASTIM-CBQV |
| Q5112 | TRASTUZUMAB-DTTB |
| Q5113 | TRASTUZUMAB-PKRB |
| Q5114 | TRASTUZUMAB-DKST |
| Q5115 | RITUXIMAB-ABBS |
What Providers Must Do
Prior Authorization Required
Oncology medications and listed supportive agents require prior authorization and review by Evolent before being dispensed or administered. Submit requests to Evolent via the web portal my.newcenturyhealth.com or by phone at 1-888-999-7713, option 1. Include the member's entire oncology regimen in the submission—omitting any component may result in denial.
- Evolent portal: my.newcenturyhealth.com
- Phone: 1-888-999-7713, option 1
- Include the complete oncology regimen with the request
Code Mapping Required for Authorization
Provider must submit the correct billing code that maps to the specific product when requesting prior authorization. If a product maps to a J- or Q-code (or a specific HCPCS code), use that code on the authorization request and on claims.
- Submit authorization requests using the HCPCS/HCFA/J- or Q-code that corresponds to the billed product
- If the product is listed under a generic or temporary code (e.g., J9999), include the product name and NDC when available to clarify mapping
Complete Regimen Submission Required
Submit the entire oncology regimen for review. Partial or incomplete regimen submissions can cause therapy components to be denied even if one agent would otherwise be authorized.
- Include all agents, supportive medications, and schedule/dosing in one request
- Do not submit only the primary agent while omitting ancillary supportive drugs
Coding-Based Denial Risk
Claims may be denied or misprocessed if the J-code (or other billing code) does not correctly map to the administered drug. Verify the code-to-product mapping prior to claim submission and correct any mismatches on the authorization and claim.
- Incorrect J-code to drug mapping is a common denial reason
- When using miscellaneous codes (e.g., J9999), document the specific product name, NDC, and supporting clinical information to reduce denial risk
Required Code–Document Mapping
When submitting prior authorization requests, include the full regimen, accurate product names, and the exact billing codes (HCPCS J- or Q-codes) that correspond to each product to streamline review and claims processing.
- Provide clinical indication, dosing, schedule, and all agents in the regimen
- List the HCPCS J- or Q-code for each product and, when applicable, include NDC or manufacturer details
Where Prior Review Applies
Review required before dispensing/administration (site of care)
Requests must be reviewed by Evolent prior to dispensing at a pharmacy or administration in a physician office, infusion center, or hospital outpatient setting.
- Applicable settings: pharmacy, office, infusion center, hospital outpatient
Biosimilars and Originator Mapping
Use mapped Q-code for biosimilars
Use the Q-code mapped to the specific biosimilar product when submitting claims; the policy lists Q-codes that correspond to originator biologics and biosimilars for proper billing.
Background and Scope
This policy maps numerous HCPCS J‑ and Q‑ codes to topical creams, injectable chemotherapies, monoclonal antibodies/biologics, and biosimilars for billing and prior authorization purposes. Examples include topical agents referenced to J9328 and J9999 (e.g., temozolomide 1 mg; fluorouracil 5% topical cream; imiquimod 5% topical cream; mechlorethamine 0.016% topical gel), many injectable chemotherapies and biologic agents listed under specific J‑codes, and multiple Q‑codes that identify biosimilars and specialty injectables (for example, Q5101, Q5106–Q5127, Q5129, Q5136). Use the mapped HCPCS J‑ or Q‑code shown in the code lists when submitting claims and prior authorization requests so the billed product matches the documented mapping.
Key Definitions and Code Notes
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