Oncology medications and supportive agents prior authorization (Medicare - Wellcare by Fidelis Care)
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Defines prior authorization and review requirements by Evolent for oncology medications and supportive agents (medical and pharmacy benefit) for Fidelis Care Medicare - Wellcare participating providers; lists drugs/HCPCS/J-codes requiring review and out-of-scope items.
No material clinical or coverage changes in this revision.
Coverage Criteria & Scope
Prior authorization / review requirement
Covered when review is performed by Evolent for listed drugs prior to dispensing or administration.
Requests can be submitted via Evolent's web portal (my.newcenturyhealth.com) or by calling 1-888-999-7713, option 1. If non-participating provider, submit request to the plan via fax 1-844-235-5090.
Do NOT submit the following to Evolent; these items are out of scope for prior authorization review: Antibiotics; Bone marrow, stem cell transplants and CAR‑T cell therapy; Controlled substances (e.g., morphine); Equipment requests (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
What Providers Must Do
Prior Authorization Required
Oncology medications and supportive agents listed by HCPCS/J/Q codes require prior review by Evolent before being dispensed or administered for members of all ages. This includes administration in physician offices, outpatient hospitals, ambulatory settings, and dispensing at pharmacies. Clinical trial agents may also be submitted to Evolent for review.
- Prior authorization required for listed oncology agents and supportive drugs (HCPCS/J/Q codes) — submit to Evolent before dispensing/administration
- Requests may be submitted via Evolent's web portal (my.newcenturyhealth.com) or by phone: 1-888-999-7713, option 1
- Non-participating providers should submit requests to the plan by fax: 1-844-235-5090
Submit Entire Oncology Regimen
Submit the entire oncology regimen to Evolent for review, even if individual agents in the regimen are not subject to prior authorization. Omitting drugs or components of the regimen when submitting may result in a denial of coverage.
- Always include all agents, schedules, and supportive medications that are part of the patient’s planned regimen
- Do not submit only select drugs — partial submissions increase risk of denial
Biosimilar Preference Notification
Fidelis Care has identified preferred biosimilar agents for oncology-related indications. Providers should note these preferences and still send the selected (including preferred biosimilars) agent(s) to Evolent for review.
- Erythropoiesis-stimulating agents: Medical benefit preferred Retacrit (if unavailable due to shortage: Epogen); Pharmacy benefit: Procrit
- Trastuzumab: Medical benefit preferred Trazimera; Pharmacy benefit options include Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera
- Bevacizumab: Medical benefit preferred Mvasi, Zirabev; Pharmacy benefit options include Avastin, Mvasi, Zirabev
- Hematopoietic agents: Medical & Pharmacy benefit preferred Zarxio
- Even when prescribing a preferred biosimilar, submit the agent and regimen to Evolent for authorization
Where Prior Review Applies
Prior review required for pharmacy, office, infusion center, and hospital outpatient
Prior review by Evolent is required before dispensing at a pharmacy or administration in physician office, infusion/ambulatory center, or hospital outpatient setting.
Biosimilar Preferences and Notes
Erythropoiesis‑stimulating agents — Retacrit preferred (medical); Procrit (pharmacy)
Erythropoiesis-stimulating agents: the policy lists Retacrit as the preferred medical‑benefit agent (use Epogen if Retacrit is unavailable due to shortage); Procrit is listed for the pharmacy benefit.
Trastuzumab — Trazimera preferred (medical); Herceptin and biosimilars (pharmacy)
Trastuzumab biosimilar preference: Trazimera is the preferred medical‑benefit trastuzumab; pharmacy benefit options include Herceptin and the listed biosimilars (Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera).
Bevacizumab — Mvasi/Zirabev preferred (medical); Avastin/Mvasi/Zirabev (pharmacy)
Bevacizumab biosimilar preference: Mvasi and Zirabev are preferred for the medical benefit; pharmacy benefit options include Avastin, Mvasi, and Zirabev.
Step Therapy / Regimen Preference
| Preferred biosimilar | Benefit | Provider action |
|---|---|---|
| Retacrit (if unavailable due to shortage: Epogen) | Medical benefit | Consider and send to Evolent for review as part of the regimen submission |
| Procrit | Pharmacy benefit | Consider and send to Evolent for review as part of the regimen submission |
| Trazimera | Medical benefit | Consider and send to Evolent for review as part of the regimen submission |
| Herceptin; Herceptin Hylecta; Herzuma; Kanjinti; Ogivri; Ontruzant; Trazimera | Pharmacy benefit | Consider and send to Evolent for review as part of the regimen submission |
| Mvasi; Zirabev | Medical benefit | Consider and send to Evolent for review as part of the regimen submission |
| Avastin; Mvasi; Zirabev | Pharmacy benefit | Consider and send to Evolent for review as part of the regimen submission |
| Zarxio | Medical & Pharmacy benefit | Consider and send to Evolent for review as part of the regimen submission |
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