Oncology medications and supportive agents prior authorization (Wellcare by Fidelis Care)
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Requires review by Evolent for oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care members prior to dispensing or administration across pharmacy, physician office, outpatient hospital, or ambulatory settings; applies to participating providers (non-participating submission instructions also provided).
No material clinical or coverage changes in this revision.
Coverage Criteria & Scope
Prior authorization / review criteria
Covered when Evolent review is completed and medically accepted indication is established
Do NOT submit the following request types 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; Immune globulins.
HCPCS / J-Codes and Effective Dates
What Providers Must Do
Evolent review required
Oncology medications and supportive agents require review by Evolent for all participating providers before dispensing or administration in any outpatient setting or physician office for members of all ages. Clinical trials may also be sent to Evolent for review. Submit requests via Evolent's web portal at my.newcenturyhealth.com or by phone at 1-888-999-7713, option 1. Non‑participating providers should submit requests to the plan via fax: 1-844-235-5090 (formerly 1-877-882-5892).
- Evolent web portal: my.newcenturyhealth.com
- Evolent phone: 1-888-999-7713, option 1
- Non-participating provider fax (plan): 1-844-235-5090
Biosimilar preference
The plan has identified preferred biosimilar agents for certain oncology-related indications. Providers should consider these preferred agents when clinically appropriate, but still submit the selected agent to Evolent for review.
- Erythropoiesis-stimulating agents — Medical benefit: Retacrit (if unavailable due to shortage: Epogen); Pharmacy benefit: Procrit
- Trastuzumab — Medical benefit: Trazimera; Pharmacy benefit: Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera
- Bevacizumab — Medical benefit: Mvasi, Zirabev; Pharmacy benefit: Avastin, Mvasi, Zirabev
- Hematopoietic agents — Medical & Pharmacy benefit: Zarxio
Submission channels
Requests may be submitted through Evolent's web portal or by phone. Non‑participating providers must send requests to the plan via the designated fax number (see above). Ensure the correct submission channel is used to avoid delays.
- Preferred submission: Evolent web portal (my.newcenturyhealth.com) or phone (1-888-999-7713, option 1)
- Non-participating providers: submit to plan fax 1-844-235-5090
Complete regimen submission required
Submit the entire oncology regimen to Evolent for review, regardless of whether individual agents appear to require prior authorization. Omitting any part of the regimen may result in a denial.
- Include all agents, supportive medications, and relevant procedural treatments that comprise the regimen
- Do not split submissions — send the full regimen even if some drugs are covered without prior authorization
Policy Background
This policy provides an administrative prior authorization review process for oncology medications and supportive agents to confirm a medically accepted indication and appropriate benefit routing (medical vs. pharmacy). It applies to requests for listed oncology medications and supportive agents that must be submitted to Evolent for review prior to dispensing or administration across settings including pharmacy dispensing, physician office, outpatient hospital, and ambulatory sites. Providers must submit the entire oncology regimen to Evolent; omitting any part of the regimen may result in a denial.
Out-of-Scope / Definitions
Step Therapy / Preferred Agents
| Drug class | Preferred agent(s) | Provider requirement |
|---|---|---|
| Erythropoiesis-stimulating agents | Medical benefit: Retacrit (if unavailable due to shortage: Epogen); Pharmacy benefit: Procrit | Preferred agents should be used when appropriate but must still be submitted to Evolent for review prior to dispensing or administration |
| Trastuzumab (HER2 agents) | Medical benefit: Trazimera; Pharmacy benefit: Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera | Preferred agents should be used when appropriate but must still be submitted to Evolent for review prior to dispensing or administration |
| Bevacizumab (VEGF inhibitors) | Medical benefit: Mvasi, Zirabev; Pharmacy benefit: Avastin, Mvasi, Zirabev | Preferred agents should be used when appropriate but must still be submitted to Evolent for review prior to dispensing or administration |
| Hematopoietic agents | Medical & Pharmacy benefit: Zarxio | Preferred agents should be used when appropriate but must still be submitted to Evolent for review prior to dispensing or administration |
Site of Care Requirements
Site-of-care review required (home, office, infusion center, hospital outpatient)
Evolent review is required before dispensing or administration at the listed sites: home, physician office, infusion center, or hospital outpatient/ambulatory setting.
- Requirement applies to dispensing at a pharmacy or administration in physician office, outpatient hospital, or ambulatory settings.
Biosimilar Preferences
Epogen / Procrit guidance — preferred ESA by benefit
Preferred erythropoiesis-stimulating agents are specified by benefit: for the medical benefit Retacrit is preferred (if unavailable due to shortage use Epogen); for the pharmacy benefit Procrit is preferred.
- Providers must still send selected agents to Evolent for review despite preference guidance.
Trastuzumab biosimilar preferences and identifiers
Preferred trastuzumab biosimilar for the medical benefit is Trazimera; multiple trastuzumab biosimilars (including Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, and Trazimera) are listed for the pharmacy benefit.
- Even preferred trastuzumab products must be submitted to Evolent for review.
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