Oncology medications and supportive agents prior authorization
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Requirements for Evolent review/prior authorization of oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care members; applies to participating providers dispensing/administering these drugs via pharmacy or medical settings.
No material clinical or coverage changes in this revision.
Coverage Criteria
Prior Authorization / Review Requirement
Covered when ALL of the following are met
Includes drugs billed to either the medical or pharmacy benefit as indicated in the code lists; clinical trials may be submitted for review. Requests can be submitted via Evolent web portal or phone; non‑participating providers submit to the plan via fax.
The following requests 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 (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.
Coding (HCPCS / J-codes / Q-codes)
Provider Actions and Submission Requirements
Evolent review required before dispensing/administration
Specified oncology medications and supportive agents listed by HCPCS/J/Q-code must be submitted to Evolent for review prior to being dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting for participating providers.
- Applies to members of all ages.
- Drugs listed in the HCPCS/J/Q code lists (see coding section) will be available via medical or pharmacy benefit as indicated.
Pharmacy‑benefit oral oncology agents require Evolent review
Oral oncology agents—many billed under J8999 or specific oral J-codes—require submission to Evolent for review and will be available via the pharmacy benefit only as listed.
Preferred biosimilars must still be submitted to Evolent
Preferred biosimilar agents are identified (e.g., Retacrit for ESAs; Trazimera for trastuzumab; Mvasi/Zirabev for bevacizumab) and should be submitted to Evolent for review; listing as preferred does not remove the requirement to submit.
- Providers must still send preferred biosimilars to Evolent for review prior to dispensing or administration.
- Both medical- and pharmacy-benefit preferred biosimilars are listed in the policy.
How to submit oncology regimen to Evolent
Submit the entire oncology regimen and the supporting clinical indication to Evolent via the web portal (my.newcenturyhealth.com) or by phone (1-888-999-7713, option 1). Non‑participating providers must submit requests to the plan via fax (1-844-235-5090).
- Include the complete regimen—omissions may lead to denials.
- Web portal and phone are the routes for participating providers; fax is for non‑participating providers.
Submit entire regimen or risk denial
Failure to submit the entire oncology regimen to Evolent may result in a denial of the request.
- The policy repeatedly instructs: “Please submit the entire oncology regimen to Evolent, regardless of prior authorization requirement. Any omissions may result in a denial.”
Prior review is required for participating providers
Requests not reviewed by Evolent for participating providers prior to dispensing or administration can trigger denials; participating providers must obtain Evolent review before dispensing/administration.
- Participating providers are required to submit requests to Evolent before providing the drug in any outpatient setting or via pharmacy.
- Clinical trials may also be sent to Evolent for review.
Background
This policy centralizes prior authorization and clinical review of oncology medications and supportive agents through Evolent to establish medical necessity and route benefit (medical vs pharmacy). Participating providers must submit oncology medication requests and the complete oncology regimen to Evolent for review prior to dispensing or administration; omissions in regimen submission may result in a denial.
Definitions
Initial Therapy Criteria
Initial review
Initial authorization requirement
Applies to members of all ages for participating providers; submit the entire oncology regimen to Evolent—omissions may result in denial.
Step Therapy / Preferred Agents
| Preferred agent | Benefit setting / notes |
|---|---|
| Erythropoiesis‑stimulating agents — Retacrit (medical benefit) | Medical benefit — Retacrit preferred; if unavailable due to shortage: Epogen. Providers must still submit to Evolent for review. |
| Erythropoiesis‑stimulating agents — Procrit (pharmacy benefit) | Pharmacy benefit — Procrit preferred. Providers must still submit to Evolent for review. |
| Trastuzumab biosimilar — Trazimera (medical benefit) | Medical benefit — Trazimera preferred. Providers must still submit to Evolent for review. |
| Trastuzumab products (pharmacy benefit) — Herceptin; Herceptin Hylecta; Herzuma; Kanjinti; Ogivri; Ontruzant; Trazimera | Pharmacy benefit — listed trastuzumab products preferred; providers must still submit to Evolent for review. |
| Bevacizumab biosimilars — Mvasi; Zirabev (medical benefit) | Medical benefit — Mvasi and Zirabev preferred; providers must still submit to Evolent for review. |
| Bevacizumab products (pharmacy benefit) — Avastin; Mvasi; Zirabev | Pharmacy benefit — listed bevacizumab products preferred; providers must still submit to Evolent for review. |
| Hematopoietic agent — Zarxio (medical & pharmacy benefit) | Medical & pharmacy benefit — Zarxio preferred; providers must still submit to Evolent for review. |
Site of Care
Review required regardless of administration setting
Drugs on the list require Evolent review regardless of site of care when administered in a physician office, outpatient hospital, ambulatory setting, or dispensed at a pharmacy.
- The review requirement applies to members of all ages and to participating providers.
Biosimilar Preferences
Epogen/Procrit — preferred biosimilar listed; submit for review
Retacrit is listed as the preferred erythropoiesis-stimulating agent (medical benefit) with Procrit noted for pharmacy benefit; providers must still submit requests for these agents to Evolent for review.
- If Retacrit is unavailable due to shortage, Epogen is noted as an alternative for the medical benefit.
Herceptin and trastuzumab biosimilars — preferred listing; submission required
Trazimera is listed as a preferred trastuzumab product (medical benefit) and multiple trastuzumab products are listed for pharmacy benefit, but providers must still submit trastuzumab requests to Evolent for review.
- Pharmacy benefit trastuzumab options include Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, and Trazimera.
Revision History
Policy additions for Wellcare by Fidelis Care (including oral J8999 listings) become effective for this plan on 5/1/2026.
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