Oncology medications and supportive agents prior authorization (Wellcare by Fidelis Care)
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This policy governs prior authorization and review requirements for oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care members, describing which drugs require review by Evolent and what providers must submit. It affects participating providers dispensing or administering oncology regimens in pharmacy, physician office, outpatient hospital, or ambulatory settings.
No material clinical or coverage changes in this revision.
Coverage criteria and scope
Prior review requirement
Covered when ALL of the following are met
Includes drugs available via medical or pharmacy benefit; separate pharmacy-only list exists. Requests may be submitted via Evolent web portal or phone; non‑participating providers should submit to the plan via fax.
Do NOT submit to Evolent for requests that are expressly listed as out-of-scope. Out-of-scope categories 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 requiring review
| C9293 | GLUCARPIDASE |
| C9307 | LINVOSELTAMAB-GCPT INJ |
| C9308 | CARBOPLATIN (AVYXA) INJ |
| J0185 | APREPITANT INJ |
| J0207 | AMIFOSTINE INJ |
| J0208 | SODIUM THIOSULFATE |
| J0594 | BUSULFAN INJ |
| J0641 | LEVOLEUCOVORIN INJ |
| J0642 | LEVOLEUCOVORIN INJ |
| J0870 | IMETELSTAT (RYTELO) / ELRANATAMAB-BCMM |
| J8999 | Many oral oncology agents listed under J8999 (abemaciclib, abiraterone, alectinib, alpelisib, apalutamide, axitinib, brigatinib, capmatinib, ceritinib, crizotinib, dabrafenib, dasatinib, enzalutamide, erlotinib, ibrutinib, imatinib, lapatinib, lenalidomide, lorlatinib, nilotinib, osimertinib, palbociclib, pazopanib, ponatinib, ribociclib, ruxolitinib, sorafenib, sunitinib, vemurafenib, venetoclax, many others as listed in source chunks 15-18) |
What providers must do
Evolent review required
Oncology medications and supportive agents listed by HCPCS/J- and Q-codes require review by Evolent prior to dispensing or administration. This applies to participating providers for drugs administered in physician offices, outpatient hospitals, ambulatory settings, and pharmacy-dispensed agents for members of all ages. Clinical trial medications may also be submitted for review.
- Submit requests via Evolent Web portal: my.newcenturyhealth.com
- Phone: 1-888-999-7713, option 1
- Non-participating providers: submit to the plan via fax 1-844-235-5090 (formerly 1-877-882-5892)
Biosimilar preference note
Preferred biosimilar agents are listed for certain oncology-related classes; however, providers should still send the preferred agent(s) to Evolent for review. Providing the preferred biosimilar does not replace the requirement to submit the complete regimen.
- 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
- Rituximab: Medical benefit — Ruxience, Truxima; Pharmacy benefit — Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima
- Bone agents and other supportive agents: listed in provider materials (e.g., zoledronic acid, pamidronate, Prolia, Xgeva)
Complete regimen submission required
Submit the entire oncology regimen to Evolent for review — do NOT omit any component (including supportive agents, biosimilars, antiemetics, growth factors, or administration codes). Omitting any part of the regimen when submitting may result in a denial.
- Submit the full regimen regardless of prior authorization requirement
- Include all medical and pharmacy benefit agents and relevant HCPCS/J-codes
- Use Evolent web portal or phone for participating providers; non-participating providers to submit to the plan via fax 1-844-235-5090
Where and how to submit
Where and how to submit: participating providers must submit requests to Evolent via the web portal (my.newcenturyhealth.com) or by phone (1-888-999-7713, option 1). Non-participating providers must submit to the plan (fax 1-844-235-5090). Include the entire regimen and all supporting documentation to facilitate review.
- Evolent Web portal: my.newcenturyhealth.com
- Evolent phone: 1-888-999-7713, option 1
- Plan fax for non-participating providers: 1-844-235-5090 (new as of 10/1/2023)
- Clinical trials may be submitted to Evolent for review
Submission and benefit assignment rules
Preferred agents and benefit assignment
Submission requirement
Omitting any part of the regimen when submitting to Evolent may result in a denial.
Preferred agent lists do not eliminate the requirement to submit for review; some agents may be available via either medical or pharmacy benefit.
Where prior review applies
Site-of-care review requirement
Drugs on the listed HCPCS/J/Q code tables require Evolent review before they are dispensed at a pharmacy or administered in a physician office, outpatient hospital, or ambulatory setting.
Biosimilar preferences and examples
Epogen/Procrit — preferred biosimilar guidance
For erythropoiesis‑stimulating agents the preferred biosimilar for the medical benefit is Retacrit (Epogen may be used if Retacrit is unavailable due to shortage); Procrit is listed for the pharmacy benefit. Preferred agents must still be submitted to Evolent for review.
Trastuzumab — Trazimera preferred (medical); multiple pharmacy options
For trastuzumab, Trazimera is listed as the preferred agent for the medical benefit; multiple trastuzumab products (Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera) are listed for the pharmacy benefit — submit for Evolent review.
Bevacizumab — preferred biosimilars listed
For bevacizumab, Mvasi and Zirabev are listed as preferred for the medical benefit; the pharmacy benefit includes Avastin and biosimilars (Mvasi, Zirabev). Submit the chosen agent to Evolent for review.
Out-of-scope categories and definitions
Background and purpose
This document lists oncology and supportive care drugs that require prior review by Evolent to establish use for a medically accepted indication. Providers must submit the entire oncology regimen to Evolent for review; omitting any part of the regimen may result in a denial. The list includes agents across medical and pharmacy benefits and identifies preferred biosimilar agents for some classes, but preferred agents still require submission to Evolent for review.
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