Oncology medications and supportive agents prior authorization
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Requires review by Evolent for oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care participating providers before dispensing or administration in outpatient/ambulatory settings; lists HCPCS/CPT codes and preferred biosimilars. Affects providers submitting oncology regimens for members in North Carolina.
No material clinical or coverage changes in this revision.
Coverage Criteria
Prior authorization / review conditions
Covered when the following administrative conditions are met
Includes clinical trials; applies to participating providers and members of all ages. Submit via Evolent web portal or phone; non-participating providers submit to the plan via fax.
Providers should include preferred biosimilar selection when applicable.
The policy excludes certain requests from submission to Evolent. Do NOT submit the following items: 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 / Billing Codes
Provider Actions & Requirements
Prior Authorization Required
Oncology medications and supportive agents require prior review by Evolent for participating providers before dispensing at a pharmacy or administration in physician offices, outpatient hospitals, or ambulatory settings. Submit requests to Evolent's web portal at my.newcenturyhealth.com or call 1-888-999-7713 (option 1). Non‑participating providers must submit requests to the plan via fax: 1-844-235-5090.
- Evolent Web portal: my.newcenturyhealth.com
- Phone: 1-888-999-7713, option 1
- Non‑participating provider fax (plan): 1-844-235-5090
Submit Entire Oncology Regimen
Please submit the entire oncology regimen to Evolent for review — not just selected agents. Failure to submit the complete regimen may result in denial of coverage.
- Submit all agents, supportive drugs, and regimen components together
- This applies regardless of whether individual drugs appear to require prior authorization
Preferred Biosimilars — Send to Evolent
Evolent reviews preferred biosimilar agents for oncology indications as noted in the plan formulary guidance. When a biosimilar is the preferred agent, providers should still send that preferred biosimilar to Evolent for review.
- Preferred erythropoiesis‑stimulating: Retacrit (medical); Procrit (pharmacy)
- Preferred trastuzumab biosimilar (medical): Trazimera; pharmacy options include Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera
- Preferred bevacizumab biosimilars (medical): Mvasi, Zirabev; pharmacy: Avastin, Mvasi, Zirabev
- Hematopoietic agents (medical & pharmacy): Zarxio
- Rituximab (medical): Ruxience, Truxima
How to Submit — Required Regimen Details
When submitting prior authorization requests include complete regimen details (all drugs, dosing, schedule, indication, and intent of therapy). Use the web portal or phone submission channels described above. Incomplete submissions or omission of regimen components increase the risk of denial or delays.
- Required details: drug names (including biosimilars), dose, route, frequency, number of cycles, clinical indication, and relevant supporting documentation
- Submission channels: Evolent web portal and phone (see Prior Authorization Required callout)
Initial Prior Authorization Criteria
Initial prior authorization
Initial authorization requirement
Includes identification of whether each agent is medical or pharmacy benefit; omissions may result in a denial.
Site of Care Requirements
Site-of-care prior review required
Evolent review is required before dispensing at a pharmacy or before administration in a physician office, outpatient hospital, or ambulatory setting.
Preferred Biosimilars
Trastuzumab — preferred biosimilars and pharmacy notes
Preferred medical‑benefit trastuzumab biosimilar: Trazimera; pharmacy benefit includes Herceptin and multiple trastuzumab biosimilars (Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera).
Bevacizumab — preferred biosimilars and pharmacy notes
Preferred medical‑benefit bevacizumab biosimilars: Mvasi and Zirabev; pharmacy benefit includes Avastin and the listed biosimilars (Mvasi, Zirabev).
Rituximab — preferred biosimilars and pharmacy notes
Preferred medical‑benefit rituximab biosimilars include Ruxience and Truxima; pharmacy benefit products include Riabni, Rituxan, Rituxan Hycela, Ruxience, and Truxima.
Definitions
Background
Oncology medications and supportive agents commonly require prior authorization to confirm that use is for a medically accepted indication and to determine appropriate benefit assignment (medical vs. pharmacy). For Medicare — Wellcare by Fidelis Care participating providers, Evolent review is required before dispensing at a pharmacy or administration in a physician office, outpatient hospital, or other ambulatory setting. Providers should submit the entire oncology regimen to Evolent for review; failure to include the full regimen may result in denial. Preferred biosimilars for several classes are identified and should be included in the submission for consideration.
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