Oncology medications and supportive agents prior authorization and review
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Governs requirement for Evolent review/prior authorization of oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care members; affects participating providers dispensing or administering listed drugs in pharmacy, physician office, outpatient hospital, or ambulatory settings.
No material clinical or coverage changes in this revision.
Coverage Criteria
Prior Authorization Requirement
Covered when ALL of the following are met
Applies to pharmacy- and medical-benefit agents listed; clinical trials may be sent to Evolent for review. Requests may be submitted via Evolent web portal or phone as specified by the plan.
Do NOT submit the following requests to Evolent: Antibiotics; Bone marrow, stem cell transplants and CAR‑T cell therapy; Controlled substances (e.g., morphine); Equipment requests (for example, infusion pumps); Genetic lab 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 Effective Dates
| C9293 | GLUCARPIDASE |
| C9307 | LINVOSELTAMAB-GCPT INJ |
| C9308 | CARBOPLATIN (AVYXA) INJ |
| J0185 | APREPITANT INJ |
| J0207 | AMIFOSTINE INJ |
| J0208 | SODIUM THIOSULFATE |
| J0594 | BUSULFAN INJ |
| J0641 | LEVOLEUCOVORIN INJ |
| J0642 | LEVOLEUCOVORIN INJ |
| J0870 | IMETELSTAT (RYTELO) |
Provider Actions and Submission Requirements
Evolent review / prior authorization required
Oncology medications and supportive agents listed in this policy must be submitted to Evolent for review (prior authorization) before being dispensed at a pharmacy or administered in a physician office, outpatient hospital, or ambulatory setting for members of all ages. Clinical trial requests may also be submitted to Evolent for review via the web portal or phone.
- Submit requests via Evolent Web portal at my.newcenturyhealth.com or call 1-888-999-7713, option 1.
- Non‑participating providers should submit requests to the plan per the fax number in the source.
Pharmacy‑benefit oral oncology agents require Evolent review (effective 1/1/2026)
Specific oral oncology agents listed (e.g., J7520, J7527, J8501, J8530, J8565, J8600, J8655, J8670 and others shown under the pharmacy section) require review by Evolent and will be available via the pharmacy benefit only effective 1/1/2026 for Wellcare by Fidelis Care.
- See pharmacy‑benefit list in the policy for the full set of oral agents subject to Evolent review and the effective date.
Preferred biosimilars — submit preferred agent to Evolent
Preferred biosimilar agents are identified for certain oncology therapies; providers should send the preferred biosimilar agents to Evolent for review when requesting authorization.
- Erythropoiesis‑stimulating agents: medical benefit Retacrit (Epogen if shortage); pharmacy benefit Procrit.
- Trastuzumab: medical benefit Trazimera (multiple trastuzumab biosimilars listed for pharmacy benefit).
- Bevacizumab: medical benefit Mvasi, Zirabev (also listed on pharmacy benefit).
Submit the entire oncology regimen to Evolent (portal/phone accepted)
Submit the entire oncology regimen to Evolent for review rather than individual agents; clinical trial requests may also be submitted via Evolent's portal or phone.
- Use Evolent Web portal at my.newcenturyhealth.com or call 1-888-999-7713, option 1 to submit requests.
- Do NOT omit regimen components when submitting — submit the full regimen.
Complete regimen submission required — omission may cause denial
Omitting portions of the entire oncology regimen when submitting to Evolent may result in a denial.
- Ensure all agents, supportive medications, and regimen components are included in the single submission to Evolent.
Site of Care Requirements
Site-of-care review required prior to dispensing or administration
Review by Evolent is required before dispensing at a pharmacy or before administration in a physician's office, outpatient hospital, or ambulatory setting.
- Applies to listed oncology medications and supportive agents for members of all ages
Biosimilar Preferences
Epoetin alfa / ESA — preferred biosimilar and pharmacy preference
For erythropoiesis-stimulating agents (ESAs), Retacrit is listed as the preferred medical-benefit biosimilar; Procrit is preferred on the pharmacy benefit.
- Medical benefit preferred: Retacrit (Epogen if shortage)
- Pharmacy benefit preferred: Procrit
Trastuzumab (medical benefit) — preferred biosimilar
For trastuzumab under the medical benefit, Trazimera is identified as the preferred biosimilar; multiple trastuzumab biosimilars are listed as available on the pharmacy benefit.
- Medical benefit preferred: Trazimera
- Pharmacy benefit examples: Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera
Bevacizumab — preferred biosimilars
For bevacizumab under the medical benefit, preferred biosimilars include Mvasi and Zirabev; pharmacy benefit lists Avastin, Mvasi, and Zirabev.
- Medical benefit preferred: Mvasi, Zirabev
- Pharmacy benefit examples: Avastin, Mvasi, Zirabev
Step Therapy / Preference Guidance
| Drug class / reference | Preferred agent(s) (benefit) | Provider action |
|---|---|---|
| Erythropoiesis‑stimulating agents (Epoetin alfa/ESA) | Retacrit (medical benefit; if unavailable due to shortage: Epogen); Procrit (pharmacy benefit) | Preferred biosimilar agents identified; providers should send preferred agent selection to Evolent for review |
| Trastuzumab (medical benefit) | Trazimera (medical benefit); pharmacy benefit options include Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera | Preferred biosimilar agents identified; providers should send preferred agent selection to Evolent for review |
| Bevacizumab | Mvasi, Zirabev (medical benefit); pharmacy benefit options include Avastin, Mvasi, Zirabev | Preferred biosimilar agents identified; providers should send preferred agent selection to Evolent for review |
| Hematopoietic agents | Zarxio (medical & pharmacy benefit) | Preferred biosimilar agents identified; providers should send preferred agent selection to Evolent for review |
Definitions / Out of Scope
Background
This policy centralizes clinical review of oncology medications and supportive agents through Evolent to establish medical necessity and determine benefit assignment (medical vs. pharmacy). Participating providers must submit oncology medication requests and supportive agents listed in the policy to Evolent for review prior to dispensing or administration, and the policy identifies preferred biosimilars and items that are out of scope for Evolent review. Additionally, submit the entire oncology regimen to Evolent; omissions may result in a denial.
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