CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents prior authorization (Medicare - Wellcare by Fidelis Care)

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.

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior authorization (Medicare - Wellcare)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent for review prior to dispensing or administering listed agents; omissions may result in denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+listed HCPCS/J-codes and Q-codes requiring review

Out-of-scope listcategories not to submit to Evolent

Biosimilar preferencespreferred biosimilars for certain oncology agents

2026-04-01Wellcare additions effective

Coverage Criteria & Scope

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior authorization / review requirement

Covered when review is performed by Evolent for listed drugs prior to dispensing or administration.

Primary requirement: Provider must submit the entire oncology regimen to Evolent and obtain review prior to dispensing at a pharmacy or administering in a physician office, outpatient hospital, or ambulatory setting for members of all ages.

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

Selected HCPCS/J codes (excerpt)HCPCS

C9293	GLUCARPIDASE
J0894
J0185	DECITABINE INJ / APREPITANT INJ (appears multiple)
J0207	LUSPATERCEPT-AAMT / AMIFOSTINE INJ (appears multiple)

HCPCS/J codes (additional list)HCPCS

J1448	TRILACICLIB INJ
J2506	PEGFILGRASTIM (ON-BODY INJECTOR) / PEGFILGRASTIM INJECTION
J9034	BENDAMUSTINE (RAPID INFUSION BENDEKA)
J9312	RITUXIMAB AND HYALURONIDASE HUMAN
J9317	PERTUZUMAB/TRASTUZUMAB/HYAL INJ
J9271	PEMBROLIZUMAB
J9349	TAFASITAMAB-CXIX INJ
J9355	TRA STUZUMAB INJ

Q-codes (select)HCPCS

Q2043	SIPULEUCEL-T AUTO CD5+
Q2050	LIPOSOMAL DOXORUBICIN
Q5101	FILGRASTIM-SNDZ
Q5116	RITUXIMAB-ABBS

Pharmacy benefit oral agents (J-/J8999 group)HCPCS|mixed

J7520	SIROLIMUS ORAL
J7527	EVEROLIMUS ORAL
J8501	APREPITANT ORAL
J8999	Multiple oral oncology agents listed (generic/oral medications) — extensive list

What Providers Must Do

Prior Authorization

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

Denial Risk

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

Note

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

Biosimilar Preferences and Notes

Billing Rule

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.

Billing Rule

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).

Billing Rule

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

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior authorization (Medicare - Wellcare)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the entire oncology regimen to Evolent for review prior to dispensing or administering listed agents; omissions may result in denial.

SourceLink

On This Page

OpenPayer

Oncology medications and supportive agents prior authorization (Medicare - Wellcare by Fidelis Care)

Coverage Criteria & Scope

HCPCS / J / Q Codes Requiring Review

What Providers Must Do

Where Prior Review Applies

Biosimilar Preferences and Notes

Step Therapy / Regimen Preference