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

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)

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

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

Review required by site of care

Evolent review is required prior to dispensing at a pharmacy or administering in a physician office, infusion center, or outpatient hospital/ambulatory setting for members of all ages.

• Applies to pharmacy, office/clinic, home infusion, infusion center, and hospital outpatient settings.

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.

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

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