CurrentFidelis CarePolicy N/A

Oncology medications prior authorization and regimen submission

This policy governs prior authorization review of oncology medications and supportive agents for Fidelis Care members, specifying that oncology regimens must be submitted to Evolent (New Century Health) before dispensing or administration and listing HCPCS/J-codes that require prior authorization. It applies to outpatient pharmacy, physician office, and ambulatory settings for members (adults, with pediatric inclusion noted).

Policy Summary

PayerFidelis Care

PolicyOncology medications prior authorization and regimen submission

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent/New Century Health (NCH) via the NCH web portal or phone before dispensing or administration to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manyHCPCS/J/Q codes listed

18+ (peds 7/1/2022)Population

Evolent/NCHReview vendor

requiredRegimen submission

Coverage Criteria and Scope

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior authorization / regimen submission requirements

Covered when prior authorization review by New Century Health (Evolent) is completed for listed oncology medications and supportive agents before dispensing or administration.

Primary requirement: Request submitted to Evolent/New Century Health (NCH) via the NCH web portal (my.newcenturyhealth.com) or by phone (1-888-999-7713, option 1) before dispensing or administration

Applies to pharmacy, physician office, outpatient hospital, and ambulatory settings; applies to members 18 and older (pediatric inclusion effective 7/1/2022).

Regimen completeness: The entire oncology regimen must be submitted to NCH; omission of regimen components may result in a denial

Providers must submit the full regimen regardless of individual drug prior authorization status; failure to submit the entire regimen may result in denial.

The following items are out of scope for submission to New Century Health (NCH) and should not be sent for prior authorization review: 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; and sickle cell diagnoses.

HCPCS / J / Q Codes and Member Inclusion

Listed HCPCS/J codes (partial list shown)HCPCSCovered

C9095	TEBENTAFUSP-TEBN INJ.
C9155	EPCORITAMAB-BYSP INJ.
C9163	INJECTION TALQUETAMAB-TGVS.
C9165	INJECTION ELRANATAMAB-BCMM.
C9293	GLUCARPIDASE.
J0185	APREPITANT INJECTION.
J0207	AMIFOSTINE 500 MG INJ.
J0208	SODIUM THIOSULFATE.
J0594	BUSULFAN 1 MG INJ.
J0641	LEVOLEUCOVORIN CALCIUM INJECTION.

1–10 of 19

1/2

Additional listed HCPCS/J/Q codes (partial list shown)HCPCSCovered

J2506	PEGFILGRASTIM DELIVERY KIT (ON-BODY INJECTOR) / PEGFILGRASTIM INJECTION
J9119	CEMIPLIMAB-RWLC
J9299	NIVOLUMAB
J9272	PEMBROLIZUMAB
J9301	OBINUTUZUMAB
J9354	ADO-TRASTUZUMAB EMTANSINE
J9355	INJECTION TRASTUZUMAB 10 MG
J9371	VINCRISTINE LIPOSOMAL.
J9380	TECLISTAMAB-CQYV INJECTION (TECVAYLI).
J9999	Miscellaneous drugs (multiple entries listed under J9999)

1–10 of 12

1/2

Member age inclusion — eligibility and submission channels (inv-05)

Member age inclusionApplies to members 18 years and older; pediatric membership included beginning 7/1/2022

Scope of reviewOncology medications and supportive agents require review before dispensing or administration

Settings coveredPharmacy, physician office, outpatient hospital, and ambulatory settings

Effective pediatric inclusion datePediatric membership included starting 7/1/2022

Submission channelsRequests may be submitted via NCH web portal (my.newcenturyhealth.com) or by calling 1-888-999-7713, option 1

Provider Submission Requirements and Channels

Note

Submission Channels

Oncology medications and supportive agents must be submitted to New Century Health (NCH) for review before they are dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting. Requests can be submitted via NCH's web portal at my.newcenturyhealth.com or by phone at 1-888-999-7713 (option 1). This requirement applies to members 18 and older, with pediatric membership included beginning 7/1/2022. Clinical trials may be sent to NCH for review effective 7/1/2022.

Submit oncology medications and supportive agents before dispensing or administration
Web portal: my.newcenturyhealth.com
Phone: 1-888-999-7713, option 1
Applies to members 18+ (pediatrics included starting 7/1/2022)
Clinical trials review may be required effective 7/1/2022

Documentation Required

Regimen Submission Required

Submit the entire oncology regimen to NCH, regardless of whether individual agents require prior authorization. All components of the regimen (antineoplastic agents and supportive care agents administered as part of the oncology regimen) must be included in the submission. Omitting drugs or regimen components may result in denial of coverage.

Include every drug and supportive agent in the oncology regimen in a single submission
Failure to submit the entire regimen may lead to denial

Prior Authorization

Prior Authorization Required

Certain HCPCS/J-codes require prior authorization review by NCH before administration or dispensing. Providers must obtain NCH prior authorization for the listed codes.

Prior authorization required for specified HCPCS/J/C codes (see policy code list)
If an individual drug in the regimen has a listed HCPCS/J code requiring prior auth, include it in the regimen submission

Note

Out-of-Scope Submissions

Requests for oncology medications and supportive agents should not be submitted to NCH when they fall into the out-of-scope categories (examples include inpatient drug requests, bone marrow/stem cell transplants, CAR-T therapy, genetic lab testing, equipment requests, controlled substances, surgeries, and certain labeled exclusions). Review the policy's out-of-scope list before submission.

Do not submit out-of-scope requests (e.g., inpatient drug requests, transplants, CAR-T, inpatient procedures, equipment)
When in doubt about scope, contact NCH via portal or phone

Denial Risk

Regimen Submission Omission — Denial Risk

Omitting any part of the oncology regimen from the submission is a denial risk. Ensure the regimen submission is complete and lists all agents, supportive medications, and associated HCPCS/J codes to avoid potential denial.

Denial risk if the entire regimen is not submitted
Include HCPCS/J codes for each agent when known

Applicable Sites of Care

Prior Authorization

Review required before dispensing/administration in listed sites of care

NCH review is required before dispensing or administration in the outpatient pharmacy, physician office, infusion center, or hospital outpatient/ambulatory settings for the listed oncology medications and supportive agents.

Do not dispense or administer listed agents in pharmacy, office, infusion center, or outpatient hospital settings without NCH review.

External Review Organization

Evolent (New Century Health / NCH) — prior authorization vendor (inv-11)

External review organizationEvolent (formerly New Century Health; NCH) is the vendor responsible for prior authorization review of oncology medications and supportive agents

Former nameNew Century Health is the former name referenced for Evolent

RolePerforms review before dispensing/administering oncology drugs for applicable members

Submission methods to NCHVia NCH web portal (my.newcenturyhealth.com) or by phone at 1-888-999-7713, option 1

Population covered under reviewMembers 18 and older (pediatrics added effective 7/1/2022)

Policy Background

This policy implements administrative clinical review for oncology medications and supportive agents through Evolent (New Century Health, NCH). Providers must submit oncology medication requests and the entire oncology regimen to NCH via the vendor’s portal or phone for prior authorization review before dispensing or administration in outpatient pharmacy, physician office, infusion center, or outpatient hospital settings. Omission of regimen components may result in a denial.

Biosimilars and Related Codes

Billing Rule

Filgrastim / Pegfilgrastim (biosimilars included) require prior authorization

Filgrastim and pegfilgrastim reference products and their biosimilars are included in the HCPCS/Q-code listings and are subject to the same prior authorization requirements as listed biologics.

Examples in the list include Q5101 (FILGRASTIM-SNDZ) and multiple J-/Q-code entries referencing pegfilgrastim and filgrastim biosimilars; submit these codes to NCH for review.