Oncology medications and supportive agents prior authorization
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This policy governs prior review/authorization requirements for oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care members and specifies agent lists, biosimilar preferences, and submission instructions for participating and non-participating providers.
No material clinical or coverage changes in this revision.
Coverage & Authorization Criteria
Prior Review / Authorization Requirement
Covered when ALL of the following are met:
Includes medical and pharmacy benefit drugs listed by HCPCS/J/Q codes; participating providers must submit via Evolent web portal or phone; non-participating providers submit to the plan via fax (updated fax 1-844-235-5090).
Submit full regimen for review (see portal or phone submission instructions).
Do NOT submit the following request types to Evolent; these items are considered out-of-scope for prior review under this oncology medication policy: antibiotics; bone marrow, stem cell transplants, and CAR-T cell therapy; controlled substances (e.g., 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.
Relevant Codes and Benefit Lists
| C9174 | DATOPOTAMAB DERUXTECAN-DLNK (DATROWAY) |
| C9175 | TREOSULFAN (GRAFAPEX) |
| C9293 | GLUCARPIDASE |
| J0185 | APREPITANT INJ |
| J0207 | AMIFOSTINE INJ |
| J0208 | SODIUM THIOSULFATE |
| J0594 | BUSULFAN INJ |
| J0641 | LEVOLEUCOVORIN INJ (variant) |
| J0642 | LEVOLEUCOVORIN INJ (variant) |
| J0870 | IMETELSTAT (RYTELO) J0870 mapping |
Provider Submission & Authorization Actions
Prior authorization required for listed oncology agents
The listed oncology medications and supportive agents identified by HCPCS/J/Q codes require review by Evolent before being dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting for members of all ages.
- Includes medical and pharmacy benefit drugs listed by code.
Pharmacy benefit review effective 9/1/2025
Certain oral oncology agents will require review by Evolent and will be available via the pharmacy benefit effective 9/1/2025 for Wellcare by Fidelis Care members.
Submission instructions — portal, phone, or plan fax
Submit requests to Evolent with the entire oncology regimen; participating providers may use Evolent's web portal or call the Evolent review line, while non‑participating providers must submit to the plan via fax.
- Participating providers: my.newcenturyhealth.com or call 1-888-999-7713, option 1.
- Non‑participating providers: submit to the plan via fax (updated fax 1-844-235-5090).
Complete regimen submission required (omissions may cause denial)
Please submit the complete oncology regimen to Evolent; omission of any regimen components may result in denial of the request.
- The policy emphasizes submitting the entire regimen regardless of individual prior authorization requirements.
Background & Scope
This document is administrative and coverage-focused. Providers must submit the entire oncology regimen to Evolent for review regardless of whether individual agents require prior authorization; omitting parts of the regimen may result in a denial. Preferred biosimilar agents are named for certain drug classes (erythropoiesis-stimulating agents, trastuzumab, bevacizumab, hematopoietic agents) and should still be submitted to Evolent for review per normal submission procedures.
Site of Care Applicability
Site-of-care review required (office, infusion center, hospital outpatient, pharmacy)
Drugs administered in a physician's office, infusion center, hospital outpatient or dispensed at a pharmacy require review by Evolent prior to administration or dispensing.
- This applies to ambulatory settings and all members of all ages.
Biosimilar & Product Preferences
Erythropoiesis‑stimulating agent preference: Retacrit (Epogen alternative)
For erythropoiesis‑stimulating agents, Retacrit is the preferred medical‑benefit agent; if Retacrit is unavailable due to shortage, Epogen is listed as the alternative. Procrit is the pharmacy‑benefit preference.
- Medical benefit: Retacrit (if unavailable due to shortage: Epogen).
- Pharmacy benefit: Procrit.
Trastuzumab biosimilar preference — Trazimera (medical benefit)
Trastuzumab preferred medical‑benefit biosimilar is Trazimera; several trastuzumab products are listed on the pharmacy benefit and should be submitted to Evolent for review.
- Medical benefit preferred: Trazimera.
- Pharmacy benefit products: Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera.
Bevacizumab/Avastin — biosimilar and pharmacy benefit listings
Preferred medical‑benefit bevacizumab biosimilars include Mvasi and Zirabev; Avastin and the biosimilars Mvasi and Zirabev are listed on the pharmacy benefit.
- Medical benefit preferred: Mvasi, Zirabev.
- Pharmacy benefit: Avastin, Mvasi, Zirabev.
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