CurrentFidelis CarePolicy N/A

Prior review/authorization for oncology medications and supportive agents

This policy governs prior review/authorization requirements for oncology medications and supportive agents for Fidelis Care Medicaid Managed Care & HealthierLife members and lists HCPCS/CPT/J/Q codes that require authorization or are out of scope. It affects providers dispensing/administering oncology agents and pharmacies for covered members.

Policy Summary

PayerFidelis Care

PolicyPrior review/authorization for oncology medications and supportive agents

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 (Evolent) via their web portal or phone prior to dispensing or administration to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+listed HCPCS/CPT/J codes and drug entries requiring review

Members 18+membership affected by review requirement

Multiplebiosimilar product entries enumerated

Severalitems providers should NOT submit to NCH

Coverage and Prior Review Criteria

Coverage criteria for prior review

Prior review/authorization is required for specified oncology medications and supportive agents; submit the full oncology regimen to New Century Health to avoid denial.

Prior review/authorization by Evolent (formerly New Century Health) is required before dispensing or administration for oncology medications and supportive agents in outpatient settings (pharmacy, physician office, outpatient hospital, or ambulatory setting).

Submit the entire oncology regimen to New Century Health; omissions may result in a denial.

Applies to members age 18 and older (pediatric membership will be included starting 7/1/2022).

Authorization is required for the HCPCS/J (and related) codes listed in this policy. Examples include (non-exhaustive): J0185, J0207, J0208, J0594, J0641, J0642, J0881, J0885, J0888, J0893, J0894, J1952 and C-series codes such as C9169, C9170, C9293 as enumerated in the coding list.

Policy Summary

PayerFidelis Care

PolicyPrior review/authorization for oncology medications and supportive agents

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 (Evolent) via their web portal or phone prior to dispensing or administration to avoid denial.

SourceLink

On This Page

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Codes Requiring Authorization and Age Threshold

HCPCS/J-codes requiring authorizationHCPCSCovered

J8999	Miscellaneous antineoplastic agents (multiple specific drug-name entries listed under this code)
J9036	Bendamustine injection (and many specific J-codes listed throughout document)

Q-codes / biosimilars listedmixedCovered

Q5101	Biosimilar and biologic product codes (examples listed)
Q5106	EPOETIN ALFA-EPBX (RETACRIT)
Q5107	BEVACIZUMAB AWWB
Q5108	PEGFILGRASTIM-JMDB
Q5110	FILGRASTIM-AAFI (NIVESTYM BIOSIMILAR)
Q5111	PEGFILGRASTIM-CBQV
Q5112	TRASTUZUMAB-DTTB
Q5113	TRASTUZUMAB-PKRB
Q5114	TRASTUZUMAB-DKST
Q5115	RITUXIMAB-ABBS

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inv-04: Age threshold for prior review

Age thresholdMembers 18 and older

Pediatric inclusion datePediatric membership included starting 7/1/2022

Settings covered by reviewPharmacy, physician office, outpatient hospital, or ambulatory setting

Provider Submission and Out-of-Scope Instructions

Prior Authorization

Prior review required — submit full regimen to New Century Health

Oncology medications and supportive agents require review by Evolent (formerly New Century Health) before being dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting for members 18 and older (pediatric membership included starting 7/1/2022). Requests can be submitted via the New Century Health web portal (mynewcenturyhealth.com) or by phone at 1-888-999-7713. Submit the entire oncology regimen to NCH; omissions may result in a denial.

Applies to outpatient pharmacy, physician office, outpatient hospital, and ambulatory settings
Submit requests at mynewcenturyhealth.com or call 1-888-999-7713
Always submit the full oncology regimen to NCH to avoid denial

Documentation Required

Do not submit out-of-scope items to New Century Health

Do NOT submit the listed out-of-scope items to New Century Health; these categories are excluded from NCH review and should be handled per standard Fidelis Care processes.

Antibiotics
Bone marrow / stem cell transplants and 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

Definitions and Examples of Out-of-Scope Requests

inv-07: Examples of items that should NOT be submitted to New Century Health

Do NOT submit (antibiotics)Antibiotics are out of scope and should not be submitted to New Century Health

Do NOT submit (transplants/CAR-T)Bone marrow/stem cell transplants and CAR‑T cell therapy are out of scope and should not be submitted to New Century Health

Do NOT submit (controlled substances)Controlled substances should not be submitted to New Century Health

Do NOT submit (equipment requests)Equipment requests (e.g., infusion pumps) are out of scope and should not be submitted to New Century Health

Do NOT submit (genetic testing)Genetic lab testing and laboratory services should not be submitted to New Century Health

Do NOT submit (hemophilia/immune globulins)Hemophilia drugs and immune globulins are out of scope and should not be submitted to New Century Health

Do NOT submit (additional exclusions)Inpatient drug requests; iron preparations; pain medications; radiopharmaceuticals; surgeries/surgical procedures; sickle cell diagnoses are out of scope and should not be submitted to New Century Health