Oncology Services - Medicare | Oncology medication prior authorization and billing list (Wellcare by Fidelis Care)
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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.
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.
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.
When Evolent review / prior authorization is required
Codes requiring Evolent review (Section III.A & III.B)
| 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 |
| 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 |
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
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
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.
- Clinical trials may be submitted to Evolent for review
Drugs may be billed via medical or pharmacy benefit
Drugs listed in Section III.A may be billed via either the medical or pharmacy benefit; drugs listed in Section III.B are pharmacy‑only. All requests must be submitted to Evolent for review regardless of formulary status or billing pathway.
- Section III.A — medical or pharmacy benefit
- Section III.B — pharmacy only
Submission channels
Requests to Evolent can be submitted through the web portal, by phone, or (for non‑participating providers) by fax to the plan. Use the portal or phone for participating‑provider submissions and the fax number shown for non‑participating providers.
- Portal: my.newcenturyhealth.com
- Phone: 1-888-999-7713, option 1
- Non‑participating provider fax (effective 10/1/2023): 1-844-235-5090
Key terms
Document changes
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.
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.
Document contains effective date line present; no specific clinical criteria changes described.
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