CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents prior authorization

This policy governs prior authorization review by Evolent for oncology medications and supportive agents for Fidelis Care Medicaid Managed Care & HealthierLife members, specifying which drugs/HCPCS require review and how to submit requests. It affects pharmacies and providers administering oncology drugs for members aged 18+ (pediatrics included starting 7/1/2022).

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit the entire oncology regimen to Evolent via the web portal or phone for prior authorization to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+member age affected

Portal + phonehow to submit requests

Manylisted codes

Full regimensubmission requirement

Coverage and Prior Authorization Requirements

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Prior Authorization Required

Covered when the following administrative conditions are met

Prior Authorization requirement: The requested oncology medication or supportive agent is included in the policy's listed HCPCS/CPT/administration codes and requires review by Evolent prior to dispensing or administration for Fidelis Care Medicaid Managed Care & HealthierLife members.

Requests must be submitted via the Evolent web portal (my.newcenturyhealth.com) or by phone (1-888-999-7713, option 1).

The following items are out of scope for Evolent prior authorization and should NOT be submitted to Evolent: 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 / Code Lists Requiring Prior Authorization

Listed HCPCS requiring prior authorization (excerpt)HCPCSCovered

C9173	FILGRASTIM-TXID (NYPOPZI)
J0897
J0185	APREPITANT INJECTION
J0207	INJECTION AMIFOSTINE 500 MG
J0208	SODIUM THIOSULFATE
J0594	INJECTION BUSULFAN 1 MG

Additional listed HCPCS/Codes (excerpt)HCPCSCovered

J2277	MOTIXAFORTIDE INJECTION
J2353	INJ OCTREOTIDE DEPOT FORM IM INJ
J2354	INJ OCTREOTIDE NON-DEPOT FORM SUBQ/IV INJ 25 MCG
J2468	INJECTION, PALONSETRON HCL (AVYXA)
J2469	INJECTION PALONOSETRON HCL 25 MCG
J2506	PEGFILGRASTIM DELIVERY KIT (ONBODY INJECTOR) / PEGFILGRASTIM INJECTION
J2562	PLERIXAFOR INJECTION
J2783	RASBURICASE INJECTION 0.5 MG
J2802	INJECTION ROMIPLOSTIM 1 MCG
J2820	SARGRAMOSTIM INJECTION 50 MCG

1–10 of 47

1/5

Oral/targeted agents and J8999 listHCPCSCovered

J8520	CAPECITABINE ORAL 150 MG
J8521	CAPECITABINE ORAL 500 MG
J8530	CYCLOPHOSPHAMIDE ORAL 25 MG
J8999	Numerous oral/targeted agents listed under J8999 (e.g., ABEMACICLIB, ACLABRUTINIB, etc.)

What Providers Must Do

Prior Authorization

Prior Authorization Required

Oncology medications and listed supportive agents require prior authorization review by Evolent before being dispensed or administered for members (includes pharmacy, physician office, outpatient hospital, and ambulatory settings). This applies to adult members 18 and older (pediatric membership will be included beginning 7/1/2022). Requests must be submitted to Evolent for review prior to dispensing or administration.

Submit via Evolent web portal: my.newcenturyhealth.com
Phone: 1-888-999-7713, option 1

Documentation Required

Complete Regimen Submission Required

Submit the entire oncology regimen to Evolent for review — do not submit only part of the regimen. Omitting components of the regimen when submitting may result in denial of the request.

Step Therapy

Step therapy pathways are not specified in this policy. When requesting authorization, include the full regimen and relevant clinical rationale; Evolent will review the submitted regimen as presented.

Denial Risk

Out-of-Scope Items — Do Not Submit to Evolent

Do NOT submit the following items to Evolent (out of scope): 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.

Initial Authorization Criteria

Initial Therapy Authorization

Initial authorization requirement

Initial authorization: Prior authorization must be obtained from Evolent before initial dispensing or administration of listed oncology medications/supportive agents for applicable members.

Submit the entire oncology regimen to Evolent when requesting initial authorization; omissions may result in denial.

Step Therapy and Sequencing

Step	Policy summary	Provider action
1	No explicit step therapy sequences are specified in this policy; instead, the policy requires submission of the entire oncology regimen for centralized review by Evolent prior to dispensing or administration.	Submit the complete oncology regimen to Evolent via the web portal or phone to request prior authorization; omitting parts of the regimen may result in denial.

Places of Administration and Dispensing

Prior Authorization

Prior authorization required across sites of care

Prior authorization review is required before dispensing or administration across sites of care, including pharmacy dispensing and administration in physician offices, hospital outpatient, or ambulatory settings.

Applies to: pharmacy | office | hospital outpatient | ambulatory

Biosimilars and Reference Biologics

Billing Rule

Biosimilars (Q-codes) require prior authorization

Biosimilars and reference biologics listed by Q-codes (e.g., filgrastim, pegfilgrastim, bevacizumab, trastuzumab, rituximab) are included in the HCPCS listings and require prior authorization as specified.

Examples shown by Q-code include Q5101, Q5110, Q5115, Q5118, Q5136, Q5146.
Follow the HCPCS listings in the policy for biosimilar prior authorization requirements.

Policy Background and Scope

This document provides administrative guidance for centralized prior authorization review of oncology medications and supportive agents by Evolent (New Century Health) for Fidelis Care Medicaid Managed Care & HealthierLife members. Prior authorization review by Evolent is required for the HCPCS/J‑coded oncology and supportive drugs listed in the policy before dispensing or administration. Providers must submit the entire oncology regimen for review—omitting any part of the regimen may result in denial—and requests may be submitted via Evolent’s web portal or by phone.