CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents — prior review by New Century Health (NCH)

Requires review/authorization by New Century Health (NCH) before dispensing or administration of oncology medications and supportive agents for Fidelis Care members (adults; pediatric inclusion begins 7/1/2022). Applies to pharmacy, physician office, outpatient hospital, and ambulatory settings.

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents — prior review by NCH

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to New Century Health (portal or phone) for prior review and authorization before dispensing or administration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCH requiredOncology med/regimen pre-review

Adults (pediatrics added 7/1/2022)Population affected

Portal or phoneHow to submit requests

Extensive J/HCPCS listDrugs requiring authorization

Coverage Criteria: Prior Review Requirements

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Prior review requirement

Covered when prior review is obtained through NCH for oncology medications and supportive agents.

NCH review required: All oncology medications and supportive agents must be reviewed by New Century Health before dispensing or administration for members aged 18 and older (pediatrics included starting 7/1/2022).

Includes medical and pharmacy benefit agents; clinical trials may be submitted to NCH for review effective 7/1/2022. Requests can be submitted via NCH web portal or by phone (1-888-999-7713).

Do not submit the following requests to New Century Health (NCH) — these items are out of scope for NCH prior review: 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 / J-Codes Requiring Authorization

Listed HCPCS/J codes requiring authorization (partial list)HCPCSCovered

C9095	TEBENTAFUSP-TEBN INJ
J0207	AMIFOSTINE 500 MG INJ
C9146	MIRVETUXIMAB SORAVTANSINE-GYNX INJ (ELAHERE)
J0208	SODIUM THIOSULFATE
J0594	BUSULFAN 1 MG INJ
C9147	TREMELIMUMAB-ACTL INJ (IMJUDO)
J0641	LEVOLEUCOVORIN CALCIUM INJECTION
C9148	TECLISTAMAB-CQYV INJ (TECVAYLI)
C9399	BENADMUSTINE INJ (VIVIMUSTA)
J0881	INJECTION DARBEPOETIN ALFA 1 MCG NON- ESRD USE

J8999/J9xxx unclassified and specific J-codes (extensive list)HCPCSCovered

J8999	Unclassified antineoplastic and related agents (many specific agents listed under this series, e.g., ABEMACICLIB; ABIRATERONE; ACALABRUTINIB; and numerous others)
J9039	BLINATUMOMAB
J9040	BLEOMYCIN SULFATE 15 UNITS
J9055	CETUXIMAB 10 MG

Additional J- and Q- code mappings and biosimilarsHCPCS|mixedCovered

J9266	PEGASPARGASE PER SINGLE DOSE
J9271	PEMBROLIZUMAB
J9293	Palifermin cross-reference (listed in mapping section)
Q5101	FILGRASTIM-SNDZ
Q5112	TRASTUZUMAB-DTTB

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Authorization is required for the oncology agents and listed HCPCS / J-codes and drugs. Requests for authorization must be submitted to New Century Health (NCH) prior to dispensing or administration.

Submit requests via NCH web portal (my.newcenturyhealth.com) or by phone at 1-888-999-7713.
Authorization is required for the HCPCS/J-codes and drug list included in this policy (see code list maintained by NCH).
Oncology medications and supportive agents require NCH review before being dispensed at a pharmacy or administered in physician office, outpatient hospital, or ambulatory settings for members (adults; pediatric inclusion effective 7/1/2022).

Note

Biosimilar Preference (Operational)

Preferred biosimilar agents for oncology-related indications are identified and operationally preferred; providers are expected to use preferred biosimilars when clinically appropriate.

Preferred biosimilars include trastuzumab (Kanjinti, Ogivri, Trazimera), bevacizumab (Mvasi, Zirabev), rituximab (Ruxience, Truxima, Riabni).
Preferred filgrastim and pegfilgrastim products are specified by benefit (medical vs pharmacy) — see NCH operational guidance for product routing.

Documentation Required

Submission Method and Requirement

Submission must be made to NCH using the designated channels and must include the full oncology regimen.

Requests can be submitted via NCH web portal at my.newcenturyhealth.com or by calling 1-888-999-7713.
Submit the entire oncology regimen (all agents, supportive care, and administration details) in a single request — do not submit only selected agents.

Denial Risk

Complete Regimen Submission Required

Omitting any agent from the regimen submission may result in denial. Always include all drugs (including supportive agents and oral/infusion components) in the regimen request to avoid delays or denials.

Failure to submit the complete regimen is a denial risk — include agents regardless of whether each agent individually requires prior authorization.
Certain items are out of scope for NCH review and should NOT be submitted (examples: antibiotics, inpatient drug requests, hemophilia drugs, CAR-T cell therapy, genetic lab testing, equipment requests). Refer to NCH guidance for full out-of-scope list.

Background and Policy Scope

This policy centralizes pre‑dispense and pre‑administration review of oncology medications and supportive agents through New Century Health (NCH). All oncology medications and supportive agents must be reviewed by NCH before dispensing or administration for Fidelis Care members aged 18 and older (pediatric inclusion effective 7/1/2022). The requirement covers agents billed under either the medical or pharmacy benefit and applies across sites of care including pharmacy, physician office, infusion/ambulatory centers, and hospital outpatient settings.

Providers must submit the entire oncology regimen to NCH for review (not individual agents in isolation). Omitting any agent from the regimen when submitting to NCH may result in a denial. Requests may be submitted via the NCH web portal or by phone.

Step Therapy / Preference Rules

Preferred agent	Reference biologic	Operational expectation
Bevacizumab Mvasi; Zirabev	Bevacizumab	Preferred biosimilar agents listed; providers may be expected to use preferred biosimilars where applicable prior to non-preferred agents
Trastuzumab Kanjinti; Ogivri; Trazimera	Trastuzumab	Preferred biosimilar agents listed; providers may be expected to use preferred biosimilars where applicable prior to non-preferred agents
Rituximab Ruxience; Truxima; Riabni	Rituximab	Preferred biosimilar agents listed; providers may be expected to use preferred biosimilars where applicable prior to non-preferred agents
Filgrastim (medical benefit: Zarxio; pharmacy benefit: Nivestym)	Filgrastim	Preference mapping identified between medical and pharmacy benefit products; use preferred benefit-specific product where applicable prior to non-preferred
Pegfilgrastim (medical: Fulphila, Udenyca, Ziextenzo, Nyvepria; pharmacy: Neulasta, Neulasta Onpro, Udenyca)	Pegfilgrastim	Preference mapping identified between medical and pharmacy benefit products; use preferred benefit-specific product where applicable prior to non-preferred

Biosimilar Preference Mapping

Billing Rule

Bevacizumab — preferred biosimilars

Bevacizumab biosimilars (Mvasi, Zirabev) are listed as preferred agents for oncology-related indications.

Use of the preferred biosimilar may be expected when clinically appropriate.

Billing Rule

Trastuzumab — preferred biosimilars

Trastuzumab biosimilars (Kanjinti, Ogivri, Trazimera) are listed as preferred agents for oncology-related indications.

Providers may be expected to select a preferred biosimilar when applicable.

Billing Rule

Rituximab — preferred biosimilars

Rituximab biosimilars (Ruxience, Truxima, Riabni) are listed as preferred agents for oncology-related indications.

Preference for biosimilars applies to oncology-related uses per policy listing.

Billing Rule

Filgrastim — benefit-specific preference mapping

Filgrastim preference mapping between medical and pharmacy benefit products is identified; Zarxio is noted for the medical benefit and Nivestym for the pharmacy benefit.

Select the product consistent with the member's benefit (medical vs pharmacy) and the listed preference.

Billing Rule

Pegfilgrastim — benefit-specific preference mapping

Pegfilgrastim preference mapping between medical and pharmacy benefit products is identified; Fulphila, Udenyca, Ziextenzo, and Nyvepria are listed for the medical benefit and Neulasta (including Onpro) and Udenyca for the pharmacy benefit.

Ensure the selected product aligns with the member's benefit type and the policy's listed preferences.

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents — prior review by NCH

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to New Century Health (portal or phone) for prior review and authorization before dispensing or administration.

SourceLink

On This Page

OpenPayer

Oncology medications and supportive agents — prior review by New Century Health (NCH)

Coverage Criteria: Prior Review Requirements

HCPCS / J-Codes Requiring Authorization

Provider Actions and Submission Requirements

Background and Policy Scope

Definitions and Preferred Agents

Step Therapy / Preference Rules

Applicable Sites of Care

Biosimilar Preference Mapping