Oncology medications and supportive agents prior authorization (Evolent/NCH review)
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This policy requires review by Evolent (formerly New Century Health / NCH) for oncology medications and supportive agents (medical or pharmacy benefit) before dispensing or administration for Medicare - Wellcare by Fidelis Care members; it applies to participating providers and describes submission channels and scope/exclusions.
No material clinical or coverage changes in this revision.
Coverage Criteria — Prior Authorization Requirements
Prior authorization / clinical review requirement
Covered when ALL of the following are met
Applies regardless of formulary status and to drugs listed by HCPCS/J/Q code in the document; submit the entire oncology regimen to Evolent (NCH); omissions may result in denial.
Requests that should NOT be submitted to Evolent (New Century Health) for review include: Antibiotics; Bone marrow, stem cell transplants and CAR‑T cell therapy; Controlled substances (for example, morphine); equipment requests such as 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.
HCPCS / J / Q Codes and Pharmacy Codes Requiring Review
| C9142 | BEVACIZUMAB-MALY. |
| J0888 | |
| C9169 | NOGAPENDEKIN ALFA INBAKICEPT-PMLN (ANKTIVA) |
| J0893 | |
| C9170 | TARLATAMAB-DLLE (IMDELLTRA) |
| C9293 | GLUCARPIDASE |
| J0185 | APREPITANT INJ |
| J0881 | DARBEPOETIN ALFA NON-ESRD |
| J0885 | EPOETIN ALFA NON-ESRD |
| J2506 | PEGFILGRASTIM (ON-BODY INJECTOR) / PEGFILGRASTIM INJECTION |
What Providers Must Do
Prior authorization required for listed HCPCS/J/Q codes
The oncology medications and supportive agents listed by HCPCS/J/Q code require review by Evolent (New Century Health) prior to dispensing or administration; this applies regardless of formulary status and includes items available via the medical or pharmacy benefit.
- Applies to dispensing at a pharmacy or administration in a physician office, outpatient hospital, or ambulatory setting.
- Includes the HCPCS/J/Q codes listed in the policy (examples shown in code tables).
Biosimilar preference — submit preferred agents to NCH
Preferred biosimilar agents are identified for certain oncology drug classes (e.g., erythropoiesis-stimulating agents, trastuzumab, bevacizumab, hematopoietic agents, rituximab); providers should still submit the chosen agent to NCH for review.
- Erythropoiesis-stimulating agents: medical benefit Retacrit (Epogen if shortage); pharmacy benefit Procrit.
- Trastuzumab: medical Trazimera; pharmacy Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera.
- Bevacizumab: medical Mvasi, Zirabev; pharmacy Avastin, Mvasi, Zirabev.
- Hematopoietic agents: Zarxio (medical & pharmacy).
- Rituximab: medical Ruxience, Truxima; pharmacy Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima.
Submission channels and required content
Submit requests to Evolent (formerly NCH) via the NCH web portal (my.newcenturyhealth.com) or by phone at 1-888-999-7713, option 1; non-participating providers must submit to the plan by fax to 1-844-235-5090.
- Include the entire oncology regimen when submitting (see complete regimen requirement).
- Clinical trials may be sent to Evolent for review.
Complete oncology regimen must be submitted
Submit the entire oncology regimen to Evolent (NCH); omitting any part of the regimen may result in a denial.
- This requirement applies regardless of prior authorization status for individual agents.
- Ensure all agents, supportive medications, and schedule details are included in the submission.
Policy Background
This policy centralizes clinical review of oncology medications and supportive agents through Evolent (formerly New Century Health) so that oncology‑related drug requests are evaluated for medical appropriateness prior to dispensing or administration. Participating providers must still submit preferred biosimilar agents when applicable; examples of preferred agents include Retacrit (medical benefit) with Epogen as the alternate if Retacrit is unavailable and Procrit for the pharmacy benefit for erythropoiesis‑stimulating agents, Trazimera (medical) and multiple trastuzumab products for pharmacy benefit, Mvasi and Zirabev for bevacizumab (medical) and Avastin, Mvasi, Zirabev for bevacizumab (pharmacy), and Zarxio for hematopoietic agents. Providers must continue to submit their chosen agents to NCH for review prior to dispensing/administration.
Definitions and Scope
Initial Therapy — Authorization Criteria
Initial therapy prior review
Initial authorization requirement
Includes items regardless of formulary status and applies to both medical and pharmacy benefits; submit the entire oncology regimen to NCH to avoid denial.
Step Therapy and Preferred Agents
| Drug / Class | Preferred agent(s) | Coverage guidance |
|---|---|---|
| Erythropoiesis-stimulating agents | Medical benefit: Retacrit (if unavailable due to shortage: Epogen); Pharmacy benefit: Procrit | Preferred erythropoiesis-stimulating agents identified; providers should still submit chosen agent to NCH for review prior to dispensing/administration. |
| Trastuzumab products | Medical benefit: Trazimera; Pharmacy benefit: Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera | Preferred trastuzumab biosimilars listed; submit to NCH for review prior to use. |
| Bevacizumab products | Medical benefit: Mvasi, Zirabev; Pharmacy benefit: Avastin, Mvasi, Zirabev | Preferred bevacizumab biosimilars listed; submit to NCH for review prior to use. |
| Hematopoietic agents | Medical & Pharmacy benefit: Zarxio | Preferred hematopoietic biosimilar identified; submit to NCH for review prior to use. |
| Rituximab products | Medical benefit: Ruxience, Truxima; Pharmacy benefit: Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima | Preferred rituximab biosimilars listed; submit to NCH for review prior to use. |
| Bone agents | Medical benefit: zoledronic acid, pamidronate; Pharmacy benefit: zoledronic acid, pamidronate, Prolia, Xgeva, risderonate, ibandronate | Preferred bone agents listed; providers should still submit chosen agent to NCH for review prior to administration. |
| Prostate cancer agents | Medical benefit: Eligard, Firmagon, Lupron, Trelstar, Vantas, Zoladex (nonpreferred: Provenge); Pharmacy benefit: Trelstar, Lupron, abiraterone acetate (non-preferred: abiraterone acetate micronized) | Preferred prostate cancer agents listed; submit to NCH for review prior to use. |
| Bendamustine | Pharmacy benefit: Bendeka | Preferred product for bendamustine identified; submit to NCH for review prior to use. |
| Antiemetics | Pharmacy benefit: Aprepitant, dronabinol, ondansetron (IV and oral), granisetron (IV and oral), metoclopramide (IV and oral), prochlorperazine (IV and oral), scopolamine patch | Preferred antiemetics listed; submit to NCH for review when applicable to oncology supportive care. |
Site of Care — Where Review Applies
home | office | infusion center | hospital outpatient — review required before dispensing or administration
Review by NCH is required before dispensing at a pharmacy or before administration in any outpatient setting (home, physician office, infusion center, or hospital outpatient) for participating providers.
- This requirement applies to members of all ages and to both medical and pharmacy benefit agents listed in the policy.
Biosimilar Preferences by Agent Class
Erythropoiesis-stimulating agents — preferred agents and notes
Preferred erythropoiesis-stimulating agents are Retacrit for the medical benefit (with Epogen if Retacrit is unavailable due to shortage) and Procrit for the pharmacy benefit; submit the selected agent to NCH for review.
- These are preferences only; NCH review is required regardless of agent selected.
Trastuzumab — preferred biosimilars listed
Preferred trastuzumab biosimilars are identified (medical benefit: Trazimera; pharmacy benefit: Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera); submit the chosen product to NCH for review.
- Preferred list is informational — NCH clinical review is still required for coverage determination.
Bevacizumab — preferred biosimilars listed
Preferred bevacizumab biosimilars are listed (medical benefit: Mvasi, Zirabev; pharmacy benefit: Avastin, Mvasi, Zirabev); providers must still submit the selected product to NCH for review.
- Selection of a preferred biosimilar does not replace the requirement for NCH review prior to dispensing/administration.
Hematopoietic agents — preferred biosimilar guidance
Preferred hematopoietic agent biosimilar is Zarxio (medical & pharmacy benefit); submit the agent to NCH for review.
- This is a preference; NCH review remains required for authorization.
Rituximab — preferred biosimilars listed
Preferred rituximab biosimilars are identified for medical and pharmacy benefit (medical: Ruxience, Truxima; pharmacy: Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima); providers must submit the chosen rituximab product to NCH for review.
- Preferred lists are informational — NCH clinical review is still required prior to dispensing/administration.
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