Essential Plan & Qualified Health Plans
Oncology medications and supportive agents require review by New Century Health (NCH) before being dispensed at a pharmacy or administered in a physician’s office, outpatient hospital, or ambulatory setting for members 18 and over. Requests can be submitted by visiting NCH’s Web portal at my.newcenturyhealth.com or calling 1-888-999-7713, option 1.
**NOTE: Please submit the entire oncology regimen to NCH, regardless of prior authorization requirement. Any omissions may result in a denial.**
I. The following requests will be directly reviewed by Fidelis Care. Please do not submit to NCH: . CAR T-cell therapy . Cablivi . Immune Globulins . Sickle Cell Disease therapy . Pain Medications . Anti-infectives . Iron preparations . Medications not being used for an oncology or oncology-related indication . Inpatient drug requests
II. Listed by HCPCS code, the following drugs require prior authorization. Note that unclassified codes may represent a number of chemotherapy agents and also require PA:
C9065 ROMIDEPSIN SOLN PALON INJ J7527 EVEROLIMUS ORAL C9069 BELANTAMAB INJ J1627 GRANISETRON ER INJ J8501 APREPITANT ORAL C9070 TAFASITAMAB-CXIX INJ J1930 LANREOTIDE INJ J8510 BUSULFAN ORAL C9078 TRILACICLIB INJ J1950 LUPRON DEPOT J8520 CAPECITABINE ORAL C9080 MELPHALAN FLU INJ J2353 OCTREOTIDE DEP INJ J8521 CAPECITABINE ORAL J0185 APREPITANT INJ J2354 OCTREOTIDE NON-DEPOT J8530 CYCLOPHOSPHAMIDE J0207 AMIFOSTINE INJ INJ ORAL J0594 BUSULFAN INJ J2425 PALIFERMIN INJ J8560 ETOPOSIDE ORAL J0641 LEVOLEUCOVORIN INJ J2469 PALONOSETRON INJ J8565 GEFITINIB ORAL J0642 LEVOLEUCOVORIN J2505 PEGFILGRASTIM (ON- J8600 MELPHALAN ORAL J0881 DARBEPOETIN ALFA INJ BODY INJ) J8655 NETUPITANT/PALON ORAL J0885 EPOETIN ALFA PROCRIT J2562 PLERIXAFOR INJ J8670 ROLAPITANT ORAL J0888 EPOETIN BETA MIRCERA J2783 RASBURICASE INJ J8700 TEMOZOLOMIDE ORAL J0894 DECITABINE INJ J2796 ROMIPLOSTIM INJ J8705 TOPOTECAN ORAL J0896 LUSPATERCEPT INJ J2797 ROLAPITANT INJ J8999 PRESCRIPTION ORAL J0897 DENOSUMAB XGEVA J2820 SARGRAMOSTIM INJ CHEMO J1442 FILGRASTIM G-CSF INJ J2860 SILTUXIMAB INJ J9000 DOXORUBICIN INJ J1447 TBO-FILGRASTIM J3315 TRIPTORELIN INJ J9015 ALDESLEUKIN INJ J1453 FOSAPREPITANT INJ J3490 UNCLASSIFIED DRUGS J9017 ARSENIC TRIOXIDE INJ J1454 FOSNETUPITANT/ J3590 UNCLASSIFIED BIOLOGICS J9019 ERWINAZE INJ
Essential Plan & Qualified Health Plans
J9022 ATEZOLIZUMAB INJ J9181 ETOPOSIDE INJ J9269 TAGRAXOFUSP-ERZS INJ J9023 AVELUMAB INJ J9185 FLUDARABINE PHOS INJ J9271 PEMBROLIZUMAB INJ J9025 AZACITIDINE INJ J9190 FLUOROURACIL INJ J9280 MITOMYCIN INJ J9027 CLOFARABINE INJ J9198 GEMCITABINEINJ J9281 MITOMYCIN J9030 BCG LIVE INTRAVESICAL J9200 FLOXURIDINE INJ PYELOCALYCEAL SOLN VAC J9201 GEMCITABINE INJ J9285 OLARATUMAB INJ J9032 BELINOSTAT INJ J9202 GOSERELIN IMPLANT J9293 MITOXANTRONE INJ J9033 BENDAMUSTINE INJ J9203 GEMTUZUMAB J9295 NECITUMUMAB INJ J9034 BENDAMUSTINE RAPID INJ OZOGAMICIN INJ J9299 NIVOLUMAB INJ J9035 BEVACIZUMAB INJ J9204 MOGAMULIZUMAB - KPKC J9301 OBINUTUZUMAB INJ J9036 BENDAMUSTINE INJ INJ J9302 OFATUMUMAB INJ J9037 BLENREP INJ J9205 LIPOSOME INJ J9303 PANITUMUMAB INJ J9039 BLINATUMOMAB INJ J9206 IRINOTECAN INJ J9305 PEMETREXED INJ J9040 BLEOMYCIN INJ J9207 IXABEPILONE INJ J9306 PERTUZUMAB INJ J9041 BORTEZOMIB INJ J9208 IFOSFAMIDE INJ J9307 PRALATREXATE INJ J9042 BRENTUXIMAB INJ J9210 EMAPALUMAB-LZSG J9308 RAMUCIRUMAB INJ J9043 CABAZITAXEL INJ J9211 IDARUBICIN INJ J9309 POLATUZUMAB VEDOTIN- J9044 BORTEZOMIB INJ J9214 INTERFERON ALFA-2B PIIQ INJ J9045 CARBOPLATIN INJ RECOMB INJ J9311 RITUXIMAB HYAL INJ J9047 CARFILZOMIB INJ J9216 INTERFERON GAMMA 1B J9312 RITUXIMAB INJ J9050 CARMUSTINE INJ J9217 LEUPROLIDE (LUPRON J9313 MOXETUMOMAB J9055 CETUXIMAB INJ DEPOT) INJ PASUDOTOX-TDFK INJ J9057 COPANLISIB INJ J9218 LEUPROLIDE INJ J9314 ROMIDEPSIN NONLYO J9060 CISPLATIN INJ J9223 LURBINECTEDIN INJ J9315 ROMIDEPSIN INJ J9065 CLADRIBINE INJ J9225 HISTRELIN IMPLANT J9316 PERTUZUMAB/ J9070 CYCLOPHOSPH INJ VANTAS TRASTUZUMAB/HYAL J9100 CYTARABINE INJ J9227 ISATUXIMAB-IRFC INJ J9317 SACITUZUMAB J9118 CALASPARGASE INJ J9228 IPILIMUMAB INJ GOVITECAN INJ J9119 CEMIPLIMAB INJ J9229 INOTUZUMAB J9320 STREPTOZOCIN INJ J9120 DACTINOMYCIN INJ OZOGAMICIN J9325 TALIMOGENE J9130 DACARBAZINE INJ J9230 MECHLORETHAMINE INJ LAHERPAREPVEC INJ J9144 DARATUMUMAB/HYAL J9245 MELPHALAN INJ J9328 TEMOZOLOMIDE INJ J9145 DARATUMUMAB INJ J9246 MELPHALAN EVOMELA INJ J9330 TEMSIROLIMUS INJ J9150 DAUNORUBICIN INJ J9261 NELARABINE INJ J9340 THIOTEPA INJ J9153 DAUNORUB / CYTAR LIP J9262 OMACETAXINE INJ J9348 NAXITAMAB-GQGK INJ J9155 DEGARELIX INJ J9263 OXALIPLATIN INJ J9349 TAFASITAMAB-CXIX J9171 DOCETAXEL INJ J9264 PACLITAXEL INJ J9351 TOPOTECAN INJ J9173 DURVALUMAB INJ PROTEINBOUND J9352 TRABECTEDIN INJ J9176 ELOTUZUMAB INJ PARTICLES J9353 MARGETUXIMAB-CMKB J9177 ENFORTUMAB INJ J9266 PEGASPARGASE INJ J9354 ADO-TRASTUZUMAB J9178 EPIRUBICIN INJ J9267 PACLITAXEL INJ EMTAN INJ J9179 ERIBULIN MESYLATE INJ J9268 PENTOSTATIN INJ J9355 TRASTUZUMAB INJ
Essential Plan & Qualified Health Plans
J9356 TRASTUZUMAB/HYAL INJ J9357 VALRUBICIN INTRAVESICAL INJ J9358 FAM-TRASTUZ DERUXTECAN J9360 VINBLASTINE SULFATE INJ J9370 VINCRISTINE SULFATE INJ J9371 VINCRISTINE LIPO INJ J9390 VINORELBINE INJ J9395 FULVESTRANT INJ J9400 ZIV-AFLIBERCEPT INJ J9600 PORFIMER INJ J9999 ANTINEOPLASTIC DRUG NOS Q2017 TENIPOSIDE INJ Q2043 SIPULEUCEL-T AUTO CD5+ Q2049 LIPODOX INJ Q2050 DOXORUBICIN LIPO INJ Q5101 FILGRASTIM-SNDZ INJ Q5106 EPOETIN ALFA-EPBX INJ Q5107 BEVACIZUMAB - AWWB INJ Q5108 PEGFILGRASTIM-JMDB INJ Q5110 FILGRASTIM-AAFI INJ Q5111 PEGFILGRASTIM-CBQV INJ Q5112 TRASTUZUMAB-DTTB INJ Q5113 TRASTUZUMAB-PKRB INJ Q5114 TRASTUZUMAB-DKST INJ Q5115 RITUXIMAB-ABBS INJ Q5116 TRASTUZUMAB-QYYP INJ Q5117 TRASTUZUMAB-ANNS INJ Q5118 BEVACIZUMAB - BVZR INJ Q5119 RITUXIMAB-PVVR INJ Q5120 PEGFILGRASTIM-BMEZ INJ Q5122 PEGFILGRASTIM-APGF INJ Q5123 RITUXIMAB-ARRX