CurrentFidelis CarePolicy N/A

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

Requires review by Evolent for oncology medications and supportive agents (medical or pharmacy benefit) for participating providers prior to dispensing or administration for members; includes list of HCPCS/J-codes and oral oncology drugs that require review. Applies to Medicare - Wellcare by Fidelis Care members.

Policy Summary

PayerFidelis Care (Wellcare Medicare)

PolicyOncology medications and supportive agents prior authorization

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical or coverage changes

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests to Evolent via my.newcenturyhealth.com or call 1-888-999-7713 (option 1) and include the entire oncology regimen.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~400+listed codes & oral agents requiring review

All agesmember ages

Participatingprovider submission

11/1/2025effective

Coverage Criteria

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 ALL of the following are met

Evolent review required: Request is submitted to Evolent for review prior to dispensing or administration for participating providers via Evolent web portal (my.newcenturyhealth.com) or by phone (1-888-999-7713, option 1)

Includes medical and pharmacy benefit agents listed; oral agents under J8999 will be processed via pharmacy benefit effective 11/01/2025 for Wellcare by Fidelis Care

Do NOT submit the following items to Evolent for review: 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 and Code Lists

Listed HCPCS/J/Q codes requiring reviewmixedCovered

C9293	GLUCARPIDASE.
C9306	TELISOTUZUMAB VEDOTIN-TLLV.
J0888
J0893
J0894
J0185	APREPITANT INJ (and other mappings shown)
J0207	AMIFOSTINE INJ (and mappings)
J0208	SODIUM THIOSULFATE (and mappings)
J0594	BUSULFAN INJ
J0641	LEVOLEUCOVORIN INJ

1–10 of 32

1/4

Biosimilar preference listingsmixed

Medical benefit	Preferred biosimilars and medical benefit examples (e.g., Retacrit for ESAs; Trazimera for trastuzumab medical benefit; Mvasi/Zirabev for bevacizumab medical benefit; Zarxio for hematopoietic agents).
Pharmacy benefit	Preferred pharmacy benefit agents listed (e.g., Procrit, Herceptin, Avastin, etc.).

inv-05: Member ages — All ages

Member agesAll ages

Applicable settingsPharmacy, physician office, outpatient hospital, ambulatory setting

Applies toMedicare - Wellcare by Fidelis Care members

Provider Actions and Submission Requirements

Prior Authorization

Evolent prior authorization required

Prior authorization review by Evolent is required for the listed oncology medications and supportive agents (medical or pharmacy benefit) before they are dispensed or administered for members of all ages. Submit requests via Evolent's web portal or by phone. If you are a non-participating provider, submit requests to the plan via fax (new fax as of 10/1/2023: 1-844-235-5090).

Evolent web portal: my.newcenturyhealth.com
Evolent phone: 1-888-999-7713, option 1
Non-participating provider fax (as of 10/1/2023): 1-844-235-5090

Prior Authorization

Oral agents – pharmacy benefit prior authorization

Effective 11/1/2025, oral oncology agents listed in the policy are processed via the pharmacy benefit and require prior authorization. Providers must submit pharmacy benefit prior authorization requests for oral agents to Evolent for review to establish medical necessity prior to dispensing.

This applies to the oral J‑codes and J8999-listed oral agents effective 11/1/2025
Examples: capecitabine, etoposide (oral), temozolomide, many targeted oral agents (see full list in policy)

Documentation Required

Regimen submission required

Submit the entire oncology regimen to Evolent for review, regardless of whether individual agents appear to require prior authorization. Omitting elements of the regimen may result in denial of the request. Certain items are out of scope and should NOT be submitted to Evolent (see list).

Do submit the full regimen (all agents, doses, schedule, and supportive care) with each request
Do NOT submit the following to Evolent: antibiotics; bone marrow/stem cell transplants and CAR‑T; controlled substances; equipment requests; genetic lab testing and laboratory services; hemophilia drugs; inpatient drug requests; inpatient radiation and chemotherapy; iron preparations; radiopharmaceuticals; surgeries/surgical procedures; sickle cell diagnoses and therapies; immune globulins
Preferred biosimilar agents are listed in the policy — preferred agents should still be sent to Evolent for review

Note

Biosimilar preference note

Preferred biosimilar agents for oncology-related indications are identified in the policy. Providers should still include these agents when submitting the regimen to Evolent for review.

Erythropoiesis‑stimulating agents: Medical benefit Retacrit (Epogen if shortage); Pharmacy benefit Procrit
Trastuzumab: Medical benefit Trazimera; Pharmacy benefit Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera
Bevacizumab: Medical benefit Mvasi, Zirabev; Pharmacy benefit Avastin, Mvasi, Zirabev
Hematopoietic agents: Medical & Pharmacy benefit Zarxio
Rituximab: Medical benefit Ruxience, Truxima; Pharmacy benefit Riabni, Rituxan, Rituxan Hycela, Ruxience, Truxima

Definitions and Out-of-Scope Items

inv-12: Out of scope with Evolent — do NOT submit

Do NOT submit - antibioticsAntibiotics are out of scope and should not be submitted to Evolent

Do NOT submit - transplants/CAR-TBone marrow, stem cell transplants and CAR‑T cell therapy should NOT be submitted to Evolent

Do NOT submit - inpatient drug requestsInpatient drug requests and inpatient radiation and chemotherapy treatments are out of scope

Do NOT submit - equipment & controlled substancesEquipment requests (e.g., infusion pumps) and controlled substances (e.g., morphine) should NOT be submitted to Evolent

Do NOT submit - genetic testing & lab servicesGenetic lab testing and laboratory services are out of scope and should not be submitted

Do NOT submit - other exclusionsHemophilia drugs; iron preparations; radiopharmaceuticals; surgeries/surgical procedures; sickle cell diagnoses and therapies; immune globulins are all out of scope

Step Therapy and Preferred Agents

Drug class / agent	Preferred agent (medical benefit)	Preferred agent (pharmacy benefit)	Coverage note
Erythropoiesis‑stimulating agents	Retacrit (if unavailable due to shortage: Epogen)	Procrit	Preferred agents listed; submit preferred agent to Evolent for review prior to dispensing or administration
Trastuzumab (HER2)	Trazimera	Herceptin; Herceptin Hylecta; Herzuma; Kanjinti; Ogivri; Ontruzant; Trazimera	Preferred agents listed by benefit channel; submit for Evolent review
Bevacizumab	Mvasi; Zirabev	Avastin; Mvasi; Zirabev	Preferred agents listed by benefit channel; submit for Evolent review
Rituximab	Ruxience; Truxima	Riabni; Rituxan; Rituxan Hycela; Ruxience; Truxima	Preferred agents listed by benefit channel; submit for Evolent review
Hematopoietic agents	Zarxio	Zarxio	Preferred agent for medical & pharmacy benefit; submit for Evolent review
Bone agents	zoledronic acid; pamidronate	zoledronic acid; pamidronate; Prolia; Xgeva; risedronate; ibandronate	Preferred agents listed by benefit channel; submit for Evolent review

Biosimilar Guidance

Billing Rule

Retacrit preferred (Epogen alternative if unavailable)

For erythropoiesis‑stimulating agents, Retacrit is the preferred medical‑benefit product; Epogen may be used if Retacrit is unavailable due to shortage.

Billing Rule

Trastuzumab biosimilar preferences — Trazimera preferred (medical)

For trastuzumab, Trazimera is the preferred medical‑benefit agent; multiple trastuzumab biosimilars are listed for the pharmacy benefit and should be submitted to Evolent for review.

Medical benefit preferred: Trazimera
Pharmacy benefit examples: Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera

Billing Rule

Bevacizumab/Avastin — preferred agents by benefit; review required

Bevacizumab/Avastin preferences are listed by benefit channel (e.g., Mvasi, Zirabev for medical benefit; Avastin, Mvasi, Zirabev for pharmacy benefit); these agents still require Evolent review.

Medical benefit preferred: Mvasi, Zirabev
Pharmacy benefit examples: Avastin, Mvasi, Zirabev

Policy Summary

PayerFidelis Care (Wellcare Medicare)

PolicyOncology medications and supportive agents prior authorization

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical or coverage changes

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests to Evolent via my.newcenturyhealth.com or call 1-888-999-7713 (option 1) and include the entire oncology regimen.

SourceLink

On This Page

OpenPayer

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

Coverage Criteria

Coding and Code Lists

Provider Actions and Submission Requirements

Background

Definitions and Out-of-Scope Items

Step Therapy and Preferred Agents

Site of Care Requirements

Biosimilar Guidance

Revision History