CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents prior review (Evolent/New Century Health)

Defines drugs and HCPCS/CPT codes requiring review by Evolent (formerly New Century Health) for Medicare - Wellcare by Fidelis Care members and lists out-of-scope items and preferred biosimilars; applies to participating providers dispensing or administering oncology medications in ambulatory, outpatient, physician office, or pharmacy settings.

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior review (Evolent/New Century Health)

Policy CodePolicy N/A

Change TypeMinor / no material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent (New Century Health) for review prior to dispensing or administration; requests via my.newcenturyhealth.com or 1-888-999-7713.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+listed codes for review

Nationalgeographic scope

11out-of-scope categories

Yespreferred biosimilars listed

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.

Prior review requirement

Covered when ALL of the following are met

NCH review requirement: The oncology medication or supportive agent is included on the policy's listed HCPCS/J/Q codes or on the oral oncology list and is intended to be dispensed at a pharmacy or administered in a physician office, outpatient hospital, or ambulatory/infusion setting; the entire oncology regimen is submitted to Evolent (formerly New Century Health) for review prior to dispensing or administration.N/A

Applies to members of all ages and participating providers; clinical trials may be submitted for review. Requests can be submitted via NCH web portal or phone as specified in policy.

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

Codes and Submission Requirements

Covered HCPCS/J/Q codes requiring NCH reviewmixedCovered

C9142	BEVACIZUMAB-MALY.
C9146	MIRVETUXIMAB SORAVTANSINE-GYNX.
C9147	TREMELIMUMAB-ACTL INJECTION.
C9148	TECLISTAMAB-CQYV INJECTION.
C9155	EPCORITAMAB-BYSP.
C9163	INJ TALQUETAMAB-TGVS.
C9165	INJ ELRANATAMAB-BCMM.
C9293	GLUCARPIDASE.
J0185	APREPITANT INJ.
J0207	AMIFOSTINE INJ.

1–10 of 63

1/7

Oral oncology medications requiring NCH review (pharmacy benefit)mixedCovered

J7520	SIROLIMUS ORAL
J7527	EVEROLIMUS ORAL
J8501	APREPITANT ORAL 5 MG
J8530	CYCLOPHOSPHAMIDE ORAL
J8565	GEFITINIB
J8600	MELPHALAN ORAL
J8655	NETUPITANT/PALONOSETRON ORAL
J8670	ROLAPITANT, ORAL
J8999	ORAL ANTINEOPLASTICS (many specific oral agents listed under J8999 in document)
J9216	INTERFERON GAMMA 1B

inv-05: Regimen submission completeness — Entire oncology regimen must be submitted

RequirementThe entire oncology regimen must be submitted to Evolent (formerly New Century Health) for review — submit all agents in the regimen regardless of individual prior authorization status.

Consequence of omissionOmitting any part of the regimen when submitting to Evolent may result in a denial.

ApplicabilityApplies to oncology medications and supportive agents dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting for participating providers and members of all ages.

Submission timingRegimen must be submitted prior to dispensing or administration for review by Evolent.

Submission channelsRequests can be submitted via NCH web portal (my.newcenturyhealth.com) or by phone at 1-888-999-7713, option 1; non‑participating providers should submit to the plan via fax 1-844-235-5090.

Provider Actions & Authorization Requirements

Prior Authorization

Prior Authorization Required

The following oncology medications and supportive agents listed by HCPCS/J- and Q-codes require prior authorization review by New Century Health (Evolent) before dispensing (pharmacy benefit) or administration (medical benefit) for members of all ages. Requests must be submitted to New Century Health (formerly NCH) via their web portal at my.newcenturyhealth.com or by phone at 1-888-999-7713, option 1. Non-participating providers should submit requests to the plan via fax (1-844-235-5090).

Prior Authorization Required: The HCPCS, J-, and Q-codes listed in this policy require prior authorization review by New Century Health (Evolent) before the drug is dispensed or administered.
Submission Channels: Submit requests via New Century Health web portal (my.newcenturyhealth.com) or by phone: 1-888-999-7713, option 1. Non-participating providers: submit to the plan via fax 1-844-235-5090.
Benefit Note: Drugs may be covered under either the medical or pharmacy benefit; authorization review is required regardless of benefit assignment.

Denial Risk

Complete Regimen Submission Required

Submit the entire oncology regimen (all agents, supportive care, and schedule) to New Century Health (Evolent) as part of the authorization request. Omitting any component of the regimen (for example, supportive agents, growth factors, or pre/post medications) may result in a denial of the request.

Complete Regimen Submission Required: Include all drugs, dosing, frequency, and duration for the full regimen when submitting to Evolent.
Denial Risk: Partial or incomplete regimen submissions may be denied.

Note

Biosimilar Preferences and Preferred Agents

Preferred biosimilar and agent guidance is provided for clinician convenience but does not replace the requirement to submit the requested agent(s) to New Century Health for review. Preferred biosimilars include, for example, Retacrit/Procrit for erythropoiesis-stimulating agents, Trazimera for trastuzumab (medical), and listed preferred agents for bevacizumab, rituximab, hematopoietic agents, and others. Continue to send the chosen/preferred agent to NCH for authorization review.

Biosimilar Preferences: Examples — Retacrit (medical) / Procrit (pharmacy) for ESAs; Trazimera (medical) and multiple trastuzumab products (pharmacy); Mvasi/Zirabev (medical) and Avastin (pharmacy) for bevacizumab; Zarxio for hematopoietic agents.
Operational Note: Preference information is informational — authorization must still be obtained for the specific product administered or dispensed.

Biosimilar Preferences and Preferred Agents

Billing Rule

Epogen / Procrit — preferred agents and fallback

For erythropoiesis‑stimulating agents, Retacrit is the preferred medical‑benefit product; if Retacrit is unavailable due to shortage, Epogen may be used. For pharmacy benefit dosing, Procrit is listed.

Billing Rule

Trastuzumab — preferred medical and pharmacy biosimilars

Trastuzumab products are preferred for the medical benefit (Trazimera); multiple trastuzumab biosimilars are also listed as available under the pharmacy benefit and should be sent to NCH for review.

Medical benefit preferred: Trazimera.
Pharmacy benefit options include: Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera and multiple TRASTUZUMAB Q‑codes.

Billing Rule

Bevacizumab — preferred biosimilars and pharmacy options

Preferred bevacizumab biosimilars are identified for the medical benefit (Mvasi, Zirabev); pharmacy benefit options include Avastin, Mvasi, and Zirabev. Providers should submit the chosen agent to NCH for prior review.

Billing Rule

Rituximab — preferred medical and pharmacy biosimilars

Preferred rituximab biosimilars are identified for the medical benefit (Ruxience, Truxima) and multiple rituximab products are listed for the pharmacy benefit; selected products must be submitted to NCH for review.

Medical benefit preferred: Ruxience, Truxima.
Pharmacy benefit options include: Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima and several Q‑codes for rituximab biosimilars.

Key Definitions

inv-11: Evolent (formerly New Century Health) — Third-party clinical review organization

DefinitionEvolent (formerly New Century Health) — third‑party clinical review organization that conducts prior review of oncology medications and regimens for participating providers.

RolePerforms prior review to establish medical acceptance of indication and to determine benefit routing (medical vs. pharmacy) for oncology medications and supportive agents.

ScopeReviews requests for medications to be dispensed at a pharmacy or administered in physician offices, outpatient hospitals, or ambulatory settings for members of all ages (participating providers).

How to contactSubmit requests via NCH web portal (my.newcenturyhealth.com) or call 1-888-999-7713, option 1; non‑participating providers submit to the plan by fax 1-844-235-5090.

Background and Scope Summary

Oncology regimens commonly combine antineoplastics, biologics, and supportive agents (for example, antiemetics and growth factors) that may be billed under either the medical or pharmacy benefit. Prior review by Evolent (formerly New Century Health) is required to establish medical acceptance of the indication and to determine benefit routing. The policy requires that the entire oncology regimen be submitted to NCH for review prior to dispensing or administration in the ambulatory settings listed in this policy, and preferred biosimilars or agents should be included when applicable.

Drug class / preferred agent	Preference / routing	Provider action
Erythropoiesis‑stimulating agents
Medical benefit: Retacrit (if unavailable due to shortage: Epogen); Pharmacy benefit: Procrit
Preferred agents should still be submitted to New Century Health (Evolent) for review prior to dispensing/administration

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior review (Evolent/New Century Health)

Policy CodePolicy N/A

Change TypeMinor / no material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent (New Century Health) for review prior to dispensing or administration; requests via my.newcenturyhealth.com or 1-888-999-7713.

SourceLink

On This Page

OpenPayer

Oncology medications and supportive agents prior review (Evolent/New Century Health)

Coverage Criteria & Scope

Codes and Submission Requirements

Provider Actions & Authorization Requirements

Biosimilar Preferences and Preferred Agents

Applicable Sites of Care

Key Definitions

Background and Scope Summary

Step Therapy and Preferred Agents