CurrentFidelis Care | Wellcare by Fidelis CarePolicy N/A

Oncology Services - Medicare | Oncology medication prior authorization and billing list (Wellcare by Fidelis Care)

Defines Evolent review/prior authorization requirements and lists HCPCS/HCPCS-like and pharmacy codes for oncology medications and supportive agents for Wellcare by Fidelis Care Medicare members; includes out-of-scope items and preferred biosimilar agents. Applies to dispensing at pharmacy or administration in physician office, outpatient hospital, or ambulatory settings.

Policy Summary

PayerFidelis Care | Wellcare by Fidelis Care

PolicyOncology Services - Medicare | Oncology medication prior authorization and billing list (Wellcare by Fidelis Care)

Policy CodePolicy N/A

Change TypeOperational / Effective date noted

Effective Date6/1/2026

Next Review DateJun 1, 2026

Key ActionParticipating providers must submit all oncology medication and supportive agent requests (entire regimen) to Evolent prior to dispensing at pharmacy or administration in office/outpatient/ambulatory settings; non-participating providers submit to plan by fax (1-844-235-5090) effective 10/1/2023.

SourceLink

POLICY UPDATE CHANGES

Effective 6/1/2026 for Wellcare by Fidelis Care - many oral agents listed under J8999 included (policy text indicates effective date for Wellcare by Fidelis Care).

Non-participating provider fax updated to 1-844-235-5090 (formerly 1-877-882-5892) effective 10/1/2023.

300+Listed HCPCS/J/Q codes and mappings

Section A & BCoverage pathways (medical/pharmacy)

Policy summary

Wellcare by Fidelis Care requires Evolent review to establish medical necessity for oncology medications and supportive agents prior to dispensing or administration. Coverage pathways are defined in two sections: Section III.A lists drugs that may be billed via either the medical or pharmacy benefit (available via medical or pharmacy benefit) and Section III.B lists drugs that are pharmacy benefit only. The requirement applies when medications are dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting, and the policy notes preferred biosimilars and a comprehensive HCPCS/J-/Q-code set for drugs that require review; certain services (e.g., antibiotics, bone marrow/stem cell transplants and CAR-T, inpatient drugs, radiopharmaceuticals, equipment requests, genetic testing, immune globulins and others) are explicitly out of scope for Evolent.

Policy metadata

PayerFidelis Care / Wellcare by Fidelis Care

Policy TitleOncology Services - Medicare | Wellcare by Fidelis Care

Policy NumberN/A

Effective DateEffective 6/1/2026 (Wellcare by Fidelis Care)

Next Review Date2026-06-01

StatusCURRENT

Key ActionSubmit oncology medication regimens to Evolent for prior authorization

When Evolent review / prior authorization is required

Codes requiring Evolent review (Section III.A & III.B)

Drugs requiring Evolent review (medical or pharmacy benefit) - HCPCS/J-codes and others (Section III.A)mixedCovered

C9293	GLUCARPIDASE
J0185	DECITABINE INJ / APREPITANT INJ (listed variants)
J0207	LUSPATERCEPT-AAMT / AMIFOSTINE INJ (listed variants)
J0208	DENOSUMAB PROLIA / SODIUM THIOSULFATE (listed variants)
J0594	BUSULFAN INJ / METHYLPREDNISOLONE ACETATE (listed variants)
J0641	LEVOLEUCOVORIN INJ
J0642	INJ DINUTUXIMAB / LEVOLEUCOVORIN INJ
J0870	IMETELSTAT (RYTELO)
J0881	DARBEPOETIN ALFA NON-ESRD
J0885	EPOETIN ALFA NON-ESRD

1–10 of 96

1/10

Drugs requiring Evolent review (pharmacy benefit only) - Oral and other pharmacy codes (Section III.B)mixedCovered

J7308	AMINOLEVULINIC ACID 20% TOPICAL (pharmacy-listed where applicable)
J8510	BUSULFAN ORAL 2 MG
J8520	CAPECITABINE ORAL
J8521	CAPECITABINE ORAL (alternate)
J8522	CAPECITABINE ORAL 50 MG
J8560	ETOPOSIDE ORAL
J8611	METHOTREXATE (JYLAMVO)
J8612	METHOTREXATE (XATMEP)
J8700	TEMOZOLOMIDE ORAL
J8705	TOPOTECAN ORAL

1–10 of 12

1/2

Codes listed in Section III.A may be billed under either the medical or pharmacy benefit; codes in Section III.B are pharmacy-benefit only. Submit all requests to Evolent for review regardless of formulary status or benefit assignment to establish coverage for a medically accepted indication.

What providers must do

Prior Authorization

Evolent review required prior to dispensing/administration

Participating providers must submit all oncology medication and supportive agent requests to Evolent for review prior to dispensing or administration. Non‑participating providers must submit requests to the plan via fax: 1-844-235-5090 (new as of 10/1/2023; formerly 1-877-882-5892).

Web portal: my.newcenturyhealth.com
Phone: 1-888-999-7713, option 1
Non‑participating provider fax (effective 10/1/2023): 1-844-235-5090

Documentation Required

Submit entire oncology regimen

Submit the entire oncology regimen for review — include all agents, supportive medications, and scheduling. Omitting components of the regimen may result in a denial. Clinical trials may be submitted to Evolent for review.

Key terms

Definitions

EvolentThird-party utilization review organization that performs prior authorization reviews for oncology medications.

Participating ProviderProvider participating with the plan network; such providers submit requests to Evolent via portal/phone.

Document changes

2026-06-01addedLatest

Effective 6/1/2026 for Wellcare by Fidelis Care: many oral oncology agents listed under J8999 included; J8999 effective date noted for pharmacy benefit list.

2023-10-01clarified

Non-participating provider fax updated to 1-844-235-5090 (formerly 1-877-882-5892) effective 10/1/2023 for submission of requests to the plan.

noted

Document contains effective date line present; no specific clinical criteria changes described.