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CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents prior authorization (Coverage Criteria)

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Defines Evolent review and prior authorization requirements for oncology medications and supportive agents for Fidelis Care Medicaid Managed Care & HealthierLife members and lists HCPCS/CPT/J-codes that require review or are out of scope.

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior authorization (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent via their web portal or phone; omissions may result in denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manyHCPCS/CPT/J-codes listed for review

~40Code-to-product mappings present

1External review vendor

18+Member age scope

multipleOut-of-scope categories

Scope and Out-of-Scope Items

The policy identifies categories of requests that are explicitly out of scope and should NOT be submitted to Evolent for review. Out-of-scope items include: Antibiotics; Bone marrow, stem cell transplants, and 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; and Zoladex.

The document contains fragmentary mappings of placeholder HCPCS J9999 entries to specific drug products and associated Q-codes. Examples shown in the fragments include topical and injectable agents such as FLUOROURACIL 0.5%, 1%, and 5% topical cream, IMIQUIMOD 5% topical cream, MECHLORETHAMINE 0.016% topical gel, MELPHALAN INJECTION, and multiple biologic/supportive agents mapped to Q-codes (for example Q5130 PEGFILGRASTIM-PBBK (FYLNETRA), Q5136 DENOSUMAB-BBDZ, and numerous trastuzumab, filgrastim, pegfilgrastim, bevacizumab, and rituximab biosimilar Q-codes). These listings are presented as code-to-product mappings without explicit coverage determinations in the provided fragments.

The supplied fragments do not include any Not Medically Necessary (NMN) statements. The content is limited to J-code placeholder mappings and Q-code associations and contains no explicit NMN language in the cited sections.

HCPCS / J-Codes and Mappings

Listed HCPCS/J-codes and unspecified groupsHCPCSCovered

C9293	GLUCARPIDASE
C9307	LINVOSELTAMAB-GCPT INJ
C9308	CARBOPLATIN (AVYXA) INJ
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)

1–10 of 158

1/16

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior authorization (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent via their web portal or phone; omissions may result in denial.

SourceLink

On This Page

HCPCS J- and Q-codes

DefinitionQ-codes shown are HCPCS Level II codes corresponding to specific biologic or biosimilar products; J9999 is used repeatedly as an unspecified/placeholder J-code mapped to specific topical, oral, or injectable drugs in the table.

PurposeQ-codes identify particular biosimilar or biologic products (e.g., Q5130 = PEGFILGRASTIM-PBBK [FYLNETRA], Q5119 = RITUXIMAB-PVVR).

Placeholder useJ9999 functions as an umbrella/unspecified other drug J-code in the document and is repeatedly mapped to specific drug names in the adjacent Q-code entries (e.g., FLUOROURACIL topical entries mapped to J9999).

Examples of Q-code mappingsQ5130 = PEGFILGRASTIM-PBBK (FYLNETRA); Q5110 = FILGRASTIM-AAFI (NIVESTYM biosimilar); Q5125 = FILGRASTIM-AYOW (RELEUKO).

Implication for billing/submissionWhen a product is listed with a Q-code, use the specific Q-code for that biologic/biosimilar rather than the generic J9999 when available to reflect the exact product billed.

Prior Authorization and Submission Requirements

Prior Authorization

Prior Authorization Required / Submission Instructions

Oncology medications and supportive agents require review by Evolent before being dispensed or administered. Requests can be submitted via Evolent's web portal at my.newcenturyhealth.com or by calling 1-888-999-7713, option 1. Please submit the entire oncology regimen to Evolent regardless of prior authorization requirement; omissions may result in denial.

Submit the full oncology regimen to Evolent — failure to include all agents may result in denial.
Submit requests via my.newcenturyhealth.com or 1-888-999-7713, option 1.

Note

Code mappings (informational)

The following HCPCS/J-code/J9999 mappings are included in the Evolent review list. This fragment contains code-to-product mappings and Q-code cross-references; no additional provider actions are specified here beyond submission of the regimen as noted above.

J9999 mappings (examples): FLUOROURACIL topical creams, IMIQUIMOD 5% topical, MELPHALAN INJ, PEGINTERFERON ALFA-2B, multiple biologics — mapped to specific Q-codes such as Q5130 (PEGFILGRASTIM-PBBK), Q5136 (DENOSUMAB-BBDZ), Q5146 (TRASTUZUMAB-STRF), Q5148 (FILGRASTIM-TXID), Q5157, Q5158, Q5159, Q5160, etc.
HCPCS/J-code lists include many specific oncology agents (see full policy code list).

Note

Provider Action — None Stated in This Fragment

None stated in these fragment-level callouts beyond the requirement to submit the full regimen and use Evolent's portal/phone contact. Where specific PA rules apply they are represented elsewhere in the policy; this fragment provides mapping and identification of codes only.

No additional provider actions are specified in this fragment.
Treat the code list as informational mapping; follow submission requirements in the prior_auth callout.

Biosimilar Code Listings

Billing Rule

FILGRASTIM listed in Q-code mappings (no preference stated)

FILGRASTIM and its biosimilars are listed in the HCPCS/Q-code mapping fragment; no preference, substitution, or tiering rule is provided in these chunks.

Example mappings include Q5101 (FILGRASTIM-SNDZ) and Q5110 (FILGRASTIM-AAFI).

Billing Rule

PEGFILGRASTIM listed in Q-code mappings (no preference stated)

PEGFILGRASTIM and its biosimilars appear in the Q-code mappings (e.g., Q5130, Q5111, Q5122) within the document fragment; no preference or substitution requirement is specified here.

Examples: Q5130 (PEGFILGRASTIM-PBBK/FYLNETRA), Q5111 (PEGFILGRASTIM-CBQV), Q5122 (PEGFILGRASTIM-APGF).

Policy Background and Notes

The background material consists of a tabulated mapping of HCPCS/J-codes (including repeated placeholder J9999 entries) to specific drug products and associated HCPCS Level II Q-codes. Representative mappings shown in the fragments include: J9999 = FLUOROURACIL 0.5%, 1%, 5% topical creams; J9999 = IMIQUIMOD 5% topical cream; J9999 = MECHLORETHAMINE 0.016% topical gel; J9999 = MELPHALAN INJECTION; and Q-code mappings such as Q5130 PEGFILGRASTIM-PBBK (FYLNETRA), Q5136 DENOSUMAB-BBDZ (JUBBONTI), Q5146 TRASTUZUMAB-STRF (HERCESSI), Q5110 FILGRASTIM-AAFI (NIVESTYM biosimilar), Q5111 PEGFILGRASTIM-CBQV, Q5118 BEVACIZUMAB - BVZR, Q5119 RITUXIMAB-PVVR, and multiple other pegfilgrastim/filgrastim and bevacizumab biosimilar Q-codes. No clinical rationale, indications, or treatment guidance are provided in these fragments—only code-to-product associations.

J9999	Repeated placeholder J-code mapped to many topical and injectable drugs in this fragment
Q5130	PEGFILGRASTIM-PBBK INJ (FYLNETRA)
Q5136	DENOSUMAB-BBDZ (JUBBONTI, WYOST)
Q5146	TRASTUZUMAB-STRF (HERCESSI)
Q5148	FILGRASTIM-TXID INJ (NYPOZI)
Q5157	DENOSUMAB0-BMWO (STOBOCLO/OSENVELT)
Q5158	DENOSUMAB-BNHT
Q5159	DENOSUMAB-DSSB (OSPOMYV/XBRYK)
Q5160	BEVACIZUMAB-NWGD (JOBEVNE)
Q0155	DRONABINOL ORAL (SYNDROS)