CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents prior authorization and review

This policy requires oncology medications and supportive agents to be reviewed by Evolent (formerly New Century Health) prior to dispensing or administration for Fidelis Care members and lists HCPCS/CPT/HCPCS-like codes that require prior authorization. It affects providers dispensing/administering oncology drugs across pharmacy, office, outpatient hospital, and ambulatory settings.

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior authorization and review

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to New Century Health via their web portal or phone for review prior to dispensing or administration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1review vendor (Evolent / New Century Health)

18+member age scope

100+listed HCPCS/J-codes requiring prior authorization

Listout-of-scope items not submitted to NCH

Coverage Criteria & 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.

Authorization requirement

Covered when reviewed and authorized by New Century Health

Regimen-level prior authorization: The entire oncology regimen must be submitted to New Century Health (NCH) for review prior to dispensing or administration.

Omissions can lead to denial; clinical trials may be submitted for review effective 7/1/2022. Submit via NCH web portal or by phone.

Out-of-scope items

Exclusions from NCH review (do not submit)

Out-of-scope requests: Requests for antibiotics; bone marrow/stem cell transplants; CAR-T cell therapy; Cablivi; controlled substances; equipment requests (infusion pumps); genetic lab testing and laboratory services; hemophilia drugs; immune globulins; inpatient drug requests; iron preparations; pain medications; radiopharmaceuticals; surgeries/surgical procedures; sickle cell diagnoses.

These items should not be submitted to New Century Health (NCH).

Do not submit the following out-of-scope items to New Century Health (NCH). These requests are excluded from NCH review and should not be sent via the NCH web portal or phone: antibiotics; bone marrow/stem cell transplants; CAR-T cell therapy; Cablivi; controlled substances; equipment requests (infusion pumps); genetic lab testing and laboratory services; hemophilia drugs; immune globulins; inpatient drug requests; iron preparations; pain medications; radiopharmaceuticals; surgeries/surgical procedures; and sickle cell diagnoses.

Codes Requiring Review

Listed HCPCS/Codes (partial group)HCPCSCovered

C9095	TEBENTAFUSP-TEBN INJ
J0641	LEVOLEUCOVORIN CALCIUM INJECTION
C9155	EPCORITAMAB-BYSP INJ
J0642	LEVOLEUCOVORIN
C9293	GLUCARPIDASE
J0881	INJECTION DARBEPOETIN ALFA MCG NON- ESRD USE
J0185	APREPITANT INJECTION
J0207	AMIFOSTINE 500 MG INJ
J0885	EPOETIN ALFA FOR NON-ESRD (EPOGEN / PROCRIT)
J0208	SODIUM THIOSULFATE

1–10 of 12

1/2

Listed HCPCS/Codes (extended list)HCPCSCovered

J0893	DECITABINE INJECTION (SUN PHARMA)
J7308	AMINOLEVULINIC ACID 20% TOPICAL
J8999	MULTIPLE SPECIFIED PRODUCTS (see list in document)
J9037	BELANTAMAB MAFODOTIN-BLMF
J9039	BLINATUMOMAB
J9040	BLEOMYCIN SULFATE 15 UNITS
J9041	BORTEZOMIB (VELCADE) FOR IV/SQ INJ
J9055	CETUXIMAB 10 MG INJ
J9271	PEMBROLIZUMAB
J9354	ADO-TRASTUZUMAB EMTANSINE

1–10 of 12

1/2

Member age inclusion

Member age scopeMembers age 18 and older; pediatric membership included starting 7/1/2022

Effective date for pediatric inclusionJuly 1, 2022

Scope noteReview requirement applies to dispensing at pharmacy or administration in physician office, outpatient hospital, or ambulatory setting

Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization required for listed HCPCS/CPT-like codes — listed codes require prior auth and review by NCH before dispensing/administration.

Submit requests to New Century Health (Evolent) via web portal or by calling 1-888-999-7713.
Includes oncology medications and supportive agents administered in physician office, outpatient hospital, ambulatory setting, and dispensed at a pharmacy for members 18 and older (pediatric membership included starting 7/1/2022).
Clinical trial requests may be submitted to NCH for review effective 7/1/2022.

Billing Rule

Biosimilar Preference

Biosimilar preference — preferred biosimilar agents listed for certain oncology agents. Use preferred biosimilars when clinically appropriate and available.

Preferred trastuzumab biosimilars: Kanjinti, Ogivri, Trazimera.
Preferred bevacizumab biosimilars: Mvasi, Zirabev.
Preferred rituximab biosimilars: Ruxience, Truxima, Riabni.
Preferred filgrastim: medical benefit Zarxio; pharmacy benefit Nivestym.
Preferred pegfilgrastim (medical benefit): Fulphila, Udenyca, Ziextenzo, Nyvepria; (pharmacy benefit): Neulasta, Neulasta Onpro, Udenyca.

Documentation Required

Regimen Submission Required

Submit the entire oncology regimen to NCH — include all agents in the plan (even those that may be out-of-scope or administered by another setting). This includes clinical trial regimens submitted starting 7/1/2022.

Use NCH web portal (py.newcenturyhealth.com) or phone 1-888-999-7713 to submit.
Include full regimen details regardless of individual prior authorization requirements.

Denial Risk

Omission / Denial Risk

Omission risk — Failure to submit the entire oncology regimen to NCH can result in denial of coverage or payment.

Do not omit agents from the regimen submission; omissions may lead to claim denials.
Do not submit out-of-scope items listed separately to NCH (e.g., inpatient drug requests, transplants, controlled substances, equipment requests); see policy for full out-of-scope list.

Background

Oncology regimens frequently include multiple therapeutic and supportive agents. To ensure regimen-level management and application of payer preferences (including biosimilar selection), the entire oncology regimen must be submitted to New Century Health (NCH) for review prior to dispensing or administration. This coordinated review requirement applies to drugs administered in the pharmacy, physician office, hospital outpatient, or ambulatory settings for members aged 18 and older (pediatric members are included beginning 7/1/2022), and clinical trial requests may be submitted to NCH effective 7/1/2022. Omitting any agent from the regimen submission can result in claim denial.

Definitions & Out-of-Scope Items

Items NOT submitted to New Century Health (out of scope)

Do not submit - antibioticsRequests for antibiotics are out of scope and should not be submitted to NCH

Do not submit - transplants & CAR-TBone marrow/stem cell transplants and CAR-T cell therapy requests are out of scope

Do not submit - named drugs & controlled substancesCablivi and controlled substances are excluded from NCH review

Do not submit - equipment & lab testingInfusion pumps (equipment requests) and genetic lab testing/laboratory services should not be submitted

Do not submit - specialty drugs & suppliesHemophilia drugs, immune globulins, inpatient drug requests, iron preparations, and radiopharmaceuticals are out of scope

Do not submit - procedures & diagnosesSurgeries/surgical procedures and sickle cell diagnoses are excluded from NCH review

Regimen Submission & Step Therapy

Step	Requirement	Notes / Preferred agents
1	Submit the entire oncology regimen to New Century Health (NCH) for review and authorization before dispensing or administration.	Omissions can result in denial; clinical trials may be submitted for review starting 7/1/2022. Preferred biosimilars to guide selection: Bevacizumab — Mvasi, Zirabev; Trastuzumab — Kanjinti, Ogivri, Trazimera; Rituximab — Ruxience, Truxima, Riabni; Filgrastim — Zarxio (medical), Nivestym (pharmacy); Pegfilgrastim — Fulphila, Udenyca, Ziextenzo, Nyvepria (medical); Neulasta/Neulasta Onpro, Udenyca (pharmacy).

Site of Care Requirements

Prior Authorization

Review required before dispensing/administration across sites of care

Review by NCH is required before dispensing or administration in the pharmacy, physician office, infusion center, or hospital outpatient/ambulatory setting for covered members.

Applies to dispensing at pharmacy and administration in physician office, outpatient hospital, or ambulatory infusion settings.
Members 18+ (pediatric included starting 7/1/2022).

Biosimilar Preferences

Billing Rule

Bevacizumab — preferred biosimilars Mvasi and Zirabev

Bevacizumab biosimilars Mvasi and Zirabev are identified as the preferred agents for bevacizumab-related indications.

Listed in policy under preferred biosimilar agents: “Bevacizumab Mvasi and Zirabev.”
Also cross-referenced in HCPCS/Q-code listings (e.g., Q5118, Q5126, Q5129 variants).

Billing Rule

Trastuzumab — preferred biosimilars listed

Preferred trastuzumab biosimilars are listed (Kanjinti, Ogivri, Trazimera and multiple trastuzumab product codes); providers should use listed biosimilars per payer preference.

Trastuzumab biosimilars named: Kanjinti, Ogivri, Trazimera; multiple trastuzumab HCPCS/Q-codes appear in the coding list (e.g., J9355, Q5112, Q5113, Q5114, Q5116, Q5117).

Billing Rule

Rituximab — preferred biosimilars listed

Preferred rituximab biosimilars are listed (Ruxience, Truxima, Riabni and other rituximab products); select payer-preferred rituximab biosimilars when clinically appropriate.

Rituximab biosimilars named: Ruxience, Truxima, Riabni; policy coding includes multiple rituximab product codes (e.g., J9311, J9312, Q5115, Q5119, Q5123).

Billing Rule

Filgrastim — preferred agent and benefit designation

Filgrastim preference and benefit designation are specified: Zarxio is noted for the medical benefit and Nivestym is noted for the pharmacy benefit.

Policy text: “Filgrastim — Medical benefit Zarxio; Pharmacy benefit: Nivestym.”
Filgrastim biosimilar codes are included in the HCPCS/Q-code lists (e.g., Q5110, Q5101).

Billing Rule

Pegfilgrastim — preferred agents and benefit designations

Pegfilgrastim preferred products and benefit designations are listed: medical benefit agents Fulphila, Udenyca, Ziextenzo, Nyvepria; pharmacy benefit agents Neulasta, Neulasta Onpro, and Udenyca.

Policy lists pegfilgrastim medical benefit: Fulphila, Udenyca, Ziextenzo, Nyvepria; pharmacy benefit: Neulasta, Neulasta Onpro, Udenyca.
Multiple pegfilgrastim HCPCS/Q-codes appear in the coding list (e.g., J2506, Q5120, Q5122, Q5127, Q5130).

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior authorization and review

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to New Century Health via their web portal or phone for review prior to dispensing or administration.

SourceLink

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