Oncology medications and supportive agents prior authorization and review
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Defines Evolent review and prior authorization requirements for oncology medications and supportive agents for Wellcare by Fidelis Care Medicare members; applies to participating providers dispensing/administering drugs in pharmacy, physician office, outpatient hospital, or ambulatory settings.
No material clinical or coverage changes in this revision.
Coverage and Submission Requirements
Prior Review Requirement
Covered when ALL of the following administrative conditions are met
Submit the full oncology regimen (include all drugs and supportive agents). Use Evolent's web portal at my.newcenturyhealth.com or call 1-888-999-7713, option 1; non‑participating providers should submit to the plan via fax 1-844-235-5090.
Do NOT submit the following categories to Evolent for review: antibiotics; bone marrow, stem cell transplants, and CAR‑T cell therapy; controlled substances (e.g., morphine); equipment requests (e.g., 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.
| Agent (class) | Preferred biosimilar / example (benefit) |
|---|---|
| Erythropoiesis‑stimulating agents | Retacrit (medical benefit; if unavailable due to shortage: Epogen); Procrit (pharmacy benefit) |
| Trastuzumab | Trazimera (medical benefit); Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera (pharmacy benefit) |
| Bevacizumab | Mvasi, Zirabev (medical benefit); Avastin, Mvasi, Zirabev (pharmacy benefit) |
| Hematopoietic agents | Zarxio (medical & pharmacy benefit) |
| Rituximab | Ruxience, Truxima (medical benefit); Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima (pharmacy benefit) |
| Bone agents | Zoledronic acid, pamidronate (medical benefit); zoledronic acid, pamidronate, Prolia, Xgeva, risedronate, ibandronate (pharmacy benefit) |
| Prostate cancer agents | Eligard, Firmagon, Lupron, Trelstar, Vantas, Zoladex (medical benefit; nonpreferred: Provenge); Trelstar, Lupron, abiraterone acetate (pharmacy benefit; nonpreferred: abiraterone acetate micronized) |
| Bendamustine | Bendeka (pharmacy benefit) |
| Antiemetics | Aprepitant, dronabinol, ondansetron (IV and oral), granisetron (IV and oral), metoclopramide (IV and oral), prochlorperazine (IV and oral), scopolamine patch (pharmacy benefit) |
Codes and Drug Entries Requiring Review
| J7520 | SIROLIMUS ORAL |
| J7527 | EVEROLIMUS ORAL |
| J8501 | APREPITANT ORAL (includes suspension and tripak) |
| J8530 | CYCLOPHOSPHAMIDE ORAL |
| J8565 | GEFITINIB |
| J8600 | MELPHALAN ORAL |
| J8655 | NETUPITANT/PALONOSETRON ORAL |
| J8670 | ROLAPITANT, ORAL |
| J8999 | Multiple oral oncology/targeted agents listed as J8999 entries (see source) |
| J8520 | CAPECITABINE ORAL |
Provider Responsibilities and Submission Workflow
Prior authorization required for listed oncology drugs
The listed HCPCS/J/CPT codes and specified oral agents require review by Evolent (prior authorization) regardless of formulary status before being dispensed or administered; some listed drugs will be processed as medical benefit and others as pharmacy benefit per the policy.
- Providers must obtain Evolent review/prior authorization for the oncology medications and supportive agents listed by code (see coding tables).
- This requirement applies regardless of formulary status and applies to both medical- and pharmacy-benefit drugs as noted in the document.
Preferred biosimilars — submit to Evolent for review
Preferred biosimilar agents are identified in the policy; providers should submit requests for these preferred agents to Evolent for review.
- Examples include Retacrit (erythropoiesis-stimulating agent), Trazimera (trastuzumab biosimilar), Mvasi (bevacizumab biosimilar), and Zarxio (hematopoietic agent).
Submission instructions — portal, phone, and non-participating provider fax
Submit the entire oncology regimen to Evolent via the web portal at my.newcenturyhealth.com or by calling 1-888-999-7713 (option 1). Non-participating providers must submit requests to the plan via fax at 1-844-235-5090.
- Use the portal or phone number for participating providers; non-participating providers should use the plan fax number listed.
Complete regimen submission required — omission may cause denial
Submit the complete oncology regimen to Evolent; omission of any drug(s) from the submitted regimen may result in a denial.
- Include all agents (anticancer and supportive) in the single regimen submission to avoid denial for omitted drugs.
Evolent review required before dispensing/administration for participating providers
Oncology medications and supportive agents must be reviewed by Evolent before being dispensed or administered for participating providers in pharmacy, physician office, outpatient hospital, or ambulatory settings.
- This review requirement applies to members of all ages and covers requests submitted for clinical trials as well.
- Participating providers must obtain Evolent review prior to dispensing or administration.
Out-of-Scope Categories and Key Terms
Policy Background and Scope
This policy governs administrative prior review and benefit routing for oncology medications and supportive agents. It establishes that participating providers must submit oncology regimens to Evolent for review prior to dispensing or administration; it is an administrative policy and does not provide clinical treatment guidance. Providers should submit the entire oncology regimen to Evolent, as omitting drugs may result in a denial.
Policy Revision History
Policy effective date for Wellcare by Fidelis Care established as 6/1/2025; oncology medications and supportive agents require Evolent review prior to dispensing or administration for participating providers.
New fax number for non‑participating providers updated to 1-844-235-5090 (replaced prior 1-877-882-5892).
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