ModifiedAnthemPolicy CC-0109

Zaltrap (ziv-aflibercept)

Clinical coverage criteria for medical-benefit use of Zaltrap (ziv-aflibercept) including approved indications, prior authorization criteria, contraindicated combinations, and applicable diagnosis codes. Applies to requests for Zaltrap under the plan's medical benefit and guides approval or denial decisions.

Policy Summary

PayerAnthem

PolicyZaltrap (ziv-aflibercept)

Policy CodePolicy CC-0109

Change TypeRevised (wording/formatting; coding reviewed)

Effective Date03/26/2026

Next Review Date

Key ActionProvider must submit documentation demonstrating diagnosis, prior oxaliplatin-containing regimen with resistance or progression, plan to use with an irinotecan-based regimen, and intent to use as a single line of therapy.

SourceLink

POLICY UPDATE CHANGES

Wording and formatting criteria updates; updated appendiceal cancer to clarify treatment applies to individuals who are not a candidate for surgery for goblet cell appendiceal adenocarcinoma (GCA); removed anal cancer from criteria.

1Primary FDA Indication (mCRC post-oxaliplatin)

4Covered tumor types specified

3Explicit contraindicated combinations

Coverage Summary

Coverage stance: covered_with_criteria. Scope: clinical coverage criteria for medical-benefit use of Zaltrap (ziv‑aflibercept) including approved indication, prior authorization criteria, contraindicated combinations, and applicable diagnosis codes for metastatic/advanced colorectal and select appendiceal adenocarcinomas. Drug and indication: Zaltrap (ziv‑aflibercept) is a recombinant fusion protein approved by the FDA in combination with FOLFIRI (5‑fluorouracil, leucovorin, irinotecan) for treatment of metastatic colorectal cancer that is resistant to or has progressed following an oxaliplatin‑containing regimen.