Oncology medications and supportive agents prior authorization (Wellcare by Fidelis Care)
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Governs prior review/authorization requirements for oncology medications and supportive agents for Wellcare by Fidelis Care (Medicare) members; affects participating providers dispensing or administering these drugs in pharmacy, physician office, outpatient hospital, or ambulatory settings.
No material clinical or coverage changes in this revision.
Coverage and Authorization Criteria
Authorization requirements
Covered when ALL of the following are met
Requires Evolent review to establish use for a medically accepted indication before dispensing or administration
Omitting any part of the regimen may result in denial
Web portal: my.newcenturyhealth.com; Phone: 1-888-999-7713, option 1; Fax for non-participating providers: 1-844-235-5090
The following items are out of scope and should NOT be submitted to Evolent: antibiotics; bone marrow, stem cell transplants, and CAR‑T cell therapy; controlled substances (e.g., morphine); equipment requests (infusion pumps); genetic lab 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. Also note the policy instruction to submit the entire oncology regimen to Evolent; omission of any agent may result in denial.
These document chunks do not list explicit coverage exclusions for the oncology agents described elsewhere; they contain code listings and an effective date. The oral specialty J‑code group (for example codes such as J7520, J7527, J8501, J8530, J8565, J8600, J8655, J8670, J8999, J9216, Q0155) and associated agents are presented as listed for Wellcare by Fidelis Care and are effective 7/1/2025. Refer to the coding section for the full code lists and the effective date for Wellcare by Fidelis Care.
HCPCS / J / Q Codes
| J7520 | SIROLIMUS ORAL |
| J7527 | EVEROLIMUS ORAL |
| J8501 | APREPITANT ORAL 5 MG / APREPITANT ORAL SUSPENSION / APREPITANT TRIPAK 125-80 MG |
| J8530 | CYCLOPHOSPHAMIDE ORAL |
| J8565 | GEFITINIB |
| J8600 | MELPHALAN ORAL |
| J8655 | NETUPITANT/PALONOSETRON ORAL |
| J8670 | ROLAPITANT, ORAL |
| J8999 | Multiple oral specialty drugs listed under J8999 (see document for many specific agents) |
| J9216 | INTERFERON GAMMA 1B |
| J7520 | SIROLIMUS ORAL |
| J7527 | EVEROLIMUS ORAL |
| J8501 | APREPITANT ORAL 5 MG / APREPITANT ORAL SUSPENSION / APREPITANT TRIPAK 125-80 MG |
| J8530 | CYCLOPHOSPHAMIDE ORAL |
| J8565 | GEFITINIB |
| J8600 | MELPHALAN ORAL |
| J8655 | NETUPITANT/PALONOSETRON ORAL |
| J8670 | ROLAPITANT, ORAL |
| J8999 | Multiple oral specialty drugs listed under J8999 (additional agents listed in chunk 19) |
| J7520 | SIROLIMUS ORAL |
| J7527 | EVEROLIMUS ORAL |
| J8501 | APREPITANT ORAL 5 MG / APREPITANT ORAL SUSPENSION / APREPITANT TRIPAK 125-80 MG |
| J8530 | CYCLOPHOSPHAMIDE ORAL |
| J8565 | GEFITINIB |
| J8600 | MELPHALAN ORAL |
| J8655 | NETUPITANT/PALONOSETRON ORAL |
| J8670 | ROLAPITANT, ORAL |
| J8999 | Multiple oral specialty drugs listed under J8999 (additional agents listed in chunk 20) |
| J9216 | INTERFERON GAMMA 1B |
| J7520 | SIROLIMUS ORAL |
| J7527 | EVEROLIMUS ORAL |
| J8501 | APREPITANT ORAL 5 MG / APREPITANT ORAL SUSPENSION / APREPITANT TRIPAK 125-80 MG |
| J8530 | CYCLOPHOSPHAMIDE ORAL |
| J8565 | GEFITINIB |
| J8600 | MELPHALAN ORAL |
| J8655 | NETUPITANT/PALONOSETRON ORAL |
| J8670 | ROLAPITANT, ORAL |
| J8999 | Multiple oral specialty drugs listed under J8999 (see chunk 21) |
Provider Responsibilities and Submission Instructions
Prior authorization required for listed oncology/supportive agents
Oncology medications and supportive agents listed by HCPCS/J/Q codes require review by Evolent before dispensing or administration for participating providers; this applies regardless of formulary status and is required to establish use for a medically accepted indication.
- Applies when drugs are dispensed at a pharmacy or administered in a physician office, outpatient hospital, or ambulatory setting.
HCPCS/J-codes for oral specialty drugs listed (prior auth implication not separately specified)
The document lists multiple HCPCS/J-codes for oral specialty drugs (including J7520, J7527, J8501, J8530, J8565, J8600, J8999, J9216, Q0155) effective 7/1/2025 for Wellcare by Fidelis Care; the chunks containing these code lists do not specify separate prior authorization mechanics beyond inclusion on the Evolent review lists.
Send preferred biosimilars to Evolent for review
Preferred biosimilar agents are identified for several drug classes; providers are instructed to send preferred agents to Evolent for review as part of the authorization process.
- Examples: Trazimera preferred (medical benefit) for trastuzumab; Mvasi and Zirabev preferred (medical benefit) for bevacizumab; Ruxience and Truxima preferred (medical benefit) for rituximab.
No step therapy rules specified
No step therapy rules are defined in the listed chunks; the policy notes biosimilar preferences but does not establish any step therapy sequencing or failure criteria.
Submission channels for authorization requests
Requests for review may be submitted via Evolent's web portal (my.newcenturyhealth.com) or by calling 1-888-999-7713, option 1; non-participating providers must submit requests to the plan by fax at 1-844-235-5090.
- Portal: my.newcenturyhealth.com
- Phone: 1-888-999-7713, option 1
- Non-participating provider fax: 1-844-235-5090
No additional documentation or prior authorization instructions in code listing sections
The chunks containing lists of oral HCPCS/J-codes do not include additional documentation or prior authorization submission instructions beyond the general portal/phone/fax guidance.
Submit entire oncology regimen; omissions may cause denial
Submit the complete oncology regimen to Evolent — omission of any part of the regimen when submitting may result in a denial.
- Include all agents in the regimen (supportive and anti-cancer agents) in the single submission to Evolent.
No other provider actions specified in these code-list chunks
These chunks consist primarily of HCPCS/J-code lists and an effective date; they do not specify additional provider actions beyond listing the codes themselves.
Where Prior Review Applies
Review required at pharmacy, office, infusion center, or hospital outpatient
All listed agents require review before being dispensed at a pharmacy or administered in a physician office, outpatient hospital, or ambulatory (infusion center) setting for members of all ages.
- Applies to medical or pharmacy benefit agents when provided in these sites of care.
Biosimilar Preferences
Trastuzumab — Trazimera preferred (medical benefit)
Trazimera is listed as the preferred medical-benefit biosimilar for trastuzumab; multiple trastuzumab products (Herceptin and biosimilars) are listed under pharmacy benefit.
- Providers should send preferred trastuzumab agents to Evolent for review.
Bevacizumab — Mvasi and Zirabev preferred (medical benefit)
Mvasi and Zirabev are listed as preferred medical-benefit biosimilars for bevacizumab; Avastin and biosimilars are listed under the pharmacy benefit.
- Providers should send preferred bevacizumab agents to Evolent for review.
Rituximab — Ruxience and Truxima preferred (medical benefit)
Ruxience and Truxima are listed as preferred medical-benefit biosimilars for rituximab; multiple rituximab products and biosimilars are listed under the pharmacy benefit.
- Providers should send preferred rituximab agents to Evolent for review.
Key Definitions
Step Therapy / Preferred Agents
| Drug class / reference drug | Preferred biosimilar(s) (medical benefit) | Preferred biosimilar(s) (pharmacy benefit) | Provider action |
|---|---|---|---|
| Erythropoiesis‑stimulating agents | Retacrit (medical benefit) | Procrit (pharmacy benefit) | Send preferred agent to Evolent for review as part of the complete regimen submission |
| Trastuzumab | Trazimera | Herceptin; Herceptin Hylecta; Herzuma; Kanjinti; Ogivri; Ontruzant; Trazimera | Send preferred agent to Evolent for review as part of the complete regimen submission |
| Bevacizumab | Mvasi; Zirabev | Avastin; Mvasi; Zirabev | Send preferred agent to Evolent for review as part of the complete regimen submission |
| Hematopoietic agents | Zarxio | Zarxio | Send preferred agent to Evolent for review as part of the complete regimen submission |
Background
This policy lists oncology medications and supportive agents (including antiemetics, growth factors, hematopoietic agents, and other supportive drugs) that require prior review by Evolent before dispensing or administration for participating providers. The requirement applies to agents identified by HCPCS/J/Q codes in the document and covers medications provided via pharmacy benefit or medical benefit across care settings (pharmacy, physician office, outpatient hospital/infusion center). Providers must submit the complete oncology regimen to Evolent for review; partial or incomplete submissions may result in denial. Submission channels and contact details for Evolent (web portal or phone) are provided in the document.
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