CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents prior review

Requires review by Evolent (formerly New Century Health) for oncology medications and supportive agents before dispensing or administration for Wellcare by Fidelis Care members; applies to participating providers and covers medical and pharmacy benefit settings.

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior review

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent (formerly NCH) for review prior to dispensing or administration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ManyListed HCPCS/J-codes and J8999 oral drug entries requiring review

All agesMember age covered

2024-05-01Policy effective date

15 itemsOut-of-scope request types

Coverage & Prior Review Requirements

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Prior Review / Medical Necessity Determination

Covered when submitted for review and approved by Evolent (formerly New Century Health/NCH).

Prior review requirement: Requests for the oncology medications and supportive agents listed (HCPCS/C/J/Q-code lists and oral agents billed under J8999) must be submitted to Evolent (formerly New Century Health) for review prior to dispensing or administration.

Applies to participating providers; includes drugs billed under medical and pharmacy benefits (oral agents billed under J8999 are pharmacy benefit only).

Do NOT submit the following request types to New Century Health (NCH) — these items are out of scope for prior review: Antibiotics; Bone marrow/stem cell transplants and CAR‑T cell therapy; Equipment requests (infusion pumps); Controlled substances (e.g., morphine); Genetic laboratory testing and laboratory services; Inpatient drug requests; Hemophilia drugs; Inpatient radiation and chemotherapy treatments; Iron preparations; Radiopharmaceuticals; Sickle cell diagnoses and therapies; Surgeries/surgical procedures; and Immune globulins.

Relevant Billing Codes

Listed HCPCS/J-code oncology medicationsHCPCSCovered

C9142	BEVACIZUMAB-MALY
C9146	MIRVETUXIMAB SORATANSINE-GYNX
C9147	TREMELIMUMAB-ACTL INJECTION
C9148	TECLISTAMAB-CQYV INJECTION
C9155	EPCORITAMAB-BYSP
J0185	APREPITANT INJ
J0207	AMIFOSTINE INJ
J1442	FILGRASTIM G-CSF 1 MCG INJ
J9035	BEVACIZUMAB 10 MG
J9190	FLUOROURACIL INJ

1–10 of 13

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Oral oncology agents billed under J8999 (pharmacy benefit only)HCPCSCovered

J8999	ABIRATERONE ACETATE ORAL
J8999	DUVELISIB ORAL
J8999	ABIRATERONE MICRONIZED ORAL
J8999	EFLORNITHINE ORAL
J8999	ABIRATERONE ORAL
J8999	ELACESTRANT ORAL
J8999	ACALABRUTINIB ORAL
J8999	ENASIDENIB ORAL
J8999	ACITRETIN ORAL
J8999	ENCORAFENIB ORAL

1–10 of 117

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What Providers Must Do

Prior Authorization

Prior Authorization Required

Oncology medications and supportive agents listed below require prior review by New Century Health (Evolent) before dispensing or administration for members of all ages. This includes medications administered in physician offices, outpatient hospitals, ambulatory settings, and pharmacy-dispensed oral agents billed under J8999. Submit requests via NCH's web portal (mynewcenturyhealth.com) or by phone at 1-888-999-7713, option 1. Non‑participating providers should fax requests to the plan at 1-844-235-5090 (formerly 1-877-882-5892).

Prior review required for listed oncology drugs (HCPCS and J-/Q-/C-codes) — submit to New Century Health (Evolent).
Prior review required for oral oncology agents billed under J8999 — pharmacy-dispensed oral agents require NCH review.
Preferred biosimilars may be listed by benefit type but still require submission to NCH for review.

Denial Risk

Complete Regimen Submission Required

Please submit the complete oncology regimen to New Century Health (Evolent). Omitting components of the regimen (for example supportive agents, growth factors, or oral agents billed under J8999) may result in denial of the request or of subsequent claims.

Include all agents in the regimen (primary therapy, supportive drugs, and any oral agents).
Do not split submissions — send the full regimen together to avoid denial risk.

Billing Rule

Biosimilar Preference — Submit for Review

Preferred biosimilar agents are identified by benefit type (medical vs pharmacy), but prior review is still required — submit requests for biosimilars to New Century Health for coverage determination.

Medical benefit examples: Retacrit (if unavailable due to shortage: Epogen) for erythropoiesis‑stimulating agents; Mvasi, Zirabev for bevacizumab where listed.
Pharmacy benefit examples: Procrit for erythropoiesis‑stimulating agents; Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera for trastuzumab where listed.

Note

Out‑of‑Scope Items — Do Not Submit to NCH

Some requests are out of scope for New Century Health and should NOT be submitted to NCH. Examples include inpatient drug requests, bone marrow/stem cell transplants and CAR‑T, radiopharmaceuticals, genetic lab testing, infusion equipment, controlled substances, and certain surgeries or procedures. Check plan guidance if unsure.

Do NOT submit to NCH: Inpatient drug requests; Bone marrow/stem cell transplants and CAR‑T; Radiopharmaceuticals; Genetic lab testing and laboratory services; Infusion pumps/equipment; Controlled substances (e.g., morphine); Inpatient radiation and chemotherapy; Hemophilia drugs; Immune globulins; Surgeries/surgical procedures.

Note

Submission Instructions

If you need assistance with submission: use NCH's portal at mynewcenturyhealth.com or call 1-888-999-7713, option 1. Non‑participating providers should fax to the plan at 1-844-235-5090. For clinical trials, submit to NCH for review as indicated.

NCH portal: mynewcenturyhealth.com
NCH phone: 1-888-999-7713, option 1
Non‑participating provider fax to plan (effective 10/1/2023): 1-844-235-5090

Policy Background

This policy defines the administrative prior review process for oncology medications and supportive agents and is not intended to provide clinical treatment guidance. It requires participating providers to submit requests for the listed oncology drugs and supportive agents to Evolent (formerly New Century Health) for review prior to dispensing or administration and instructs that the entire oncology regimen be submitted so the reviewer can determine medical necessity; it does not contain disease‑specific treatment algorithms or clinical management recommendations.

Key Definitions

Evolent (formerly New Century Health) — third‑party reviewer required for oncology medication requests

DefinitionEvolent (formerly New Century Health) — third-party review organization that must review oncology medication and supportive agent requests for participating providers prior to dispensing at a pharmacy or administration in a physician's office, outpatient hospital, or ambulatory setting.

ScopeApplies to Wellcare by Fidelis Care members of all ages for participating providers; includes pharmacy and medical benefit drugs (oral agents billed under J8999 are pharmacy benefit entries requiring review).

How to submitSubmit requests via the NCH web portal (mynewcenturyhealth.com) or by phone at 1-888-999-7713, option 1; non‑participating providers submit to the plan fax: 1-844-235-5090.

Required documentationSubmit the entire oncology regimen to Evolent (formerly NCH); omissions of regimen components may result in a denial.

Settings coveredReview is required before dispensing or administration in pharmacy, physician office, outpatient hospital, or ambulatory settings.

Step Therapy & Preferred Agents

Benefit type	Preferred biosimilar(s)	Provider action
Medical benefit	Retacrit (preferred for erythropoiesis‑stimulating agents); Trazimera (trastuzumab); Mvasi, Zirabev (bevacizumab); Zarxio (hematopoietic agents)	Submit request to Evolent (New Century Health) for prior review before administration; preferred agents should still be sent to NCH for review.
Pharmacy benefit	Procrit (erythropoiesis‑stimulating agents); Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera (trastuzumab); Avastin, Mvasi, Zirabev (bevacizumab); Zarxio (hematopoietic agents)	Submit request to Evolent (New Century Health) for prior review before dispensing; preferred agents should still be sent to NCH for review.

Where Review Applies

Prior Authorization

Review required prior to dispensing or administration (office/outpatient/pharmacy)

Prior review by Evolent (New Century Health) is required before the drug is dispensed at a pharmacy or administered in a physician office, outpatient hospital, or ambulatory setting.

Applies to members of all ages and to participating providers.
Includes both pharmacy-dispensed and medically administered oncology medications and supportive agents.

Biosimilar Guidance