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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsBlue Cross Blue Shield - Louisiana bevacizumab Cov…
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    Currentblue cross blue shield - louisianaPolicy MA-214

    bevacizumab Products

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    Policy MA-214 governs coverage and medical necessity criteria for bevacizumab and its biosimilars for members of Blue Cross Blue Shield - Louisiana, including Medicare Advantage members, when benefits and medical necessity criteria are met.

    Policy Summary
    Payerblue cross blue shield - louisiana
    Policybevacizumab Products
    Policy CodePolicy MA-214
    Change TypeNo material changes
    Effective Date07/01/2026
    Last ReviewApr 21, 2026
    Next Review Date04/01/2027
    Key ActionObtain prior authorization and document trial and failure of both preferred biosimilars Mvasi and Zirabev before requesting coverage for non-preferred bevacizumab products.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    7bevacizumab products named
    Allprior auth required
    J3490, J3590, J9035example HCPCS codes
    07/01/2026effective

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    Coverage Criteria for Bevacizumab and Biosimilars

    Coverage eligibility and patient selection

    Covered when ALL of the following are met:

    Benefits and medical necessity: Benefits are available in the member's contract/certificate AND medical necessity criteria and guidelines are met.

    Source: policy prerequisites

    Preferred products considered first: Bevacizumab-awwb (Mvasi) AND bevacizumab-bvzr (Zirabev) are considered eligible for coverage as preferred biosimilars.

    Based on policy statement that Mvasi and Zirabev may be considered eligible for coverage.

    Trial requirement for non-preferred products: For coverage consideration of bevacizumab (Avastin) or other non-preferred bevacizumab products (Alymsys, Avzivi, Jobevne, Vegzelma), the patient must have tried and failed BOTH Mvasi and Zirabev (e.g., intolerance or inadequate response), unless clinical evidence or patient history indicates those products would be ineffective or cause adverse reaction.

    Patient selection criterion from policy; not applicable to intravitreal use.

    Coverage of bevacizumab products is granted only when ALL coverage criteria are met, including that benefits for the requested service are available in the member’s contract and medical necessity criteria and guidelines are satisfied. The policy identifies bevacizumab-awwb (Mvasi) and bevacizumab-bvzr (Zirabev) as the preferred biosimilar products and these should be considered first for therapy. For consideration of coverage for other bevacizumab products, the patient must have tried and failed BOTH Mvasi and Zirabev (for example, due to intolerance or inadequate response), unless there is documented clinical evidence or patient history demonstrating those products would be ineffective or cause an adverse reaction.

    The Health Plan will not approve non-preferred bevacizumab products unless the patient selection criteria are satisfied. Specifically, use of Avastin (bevacizumab) and the listed non-preferred biosimilars (Alymsys, Avzivi, Jobevne, Vegzelma) is considered not medically necessary when the required trial of both preferred biosimilars (Mvasi and Zirabev) has not been documented. Providers should document trials, intolerance, or inadequate response to the preferred products when requesting coverage for non-preferred bevacizumab products.

    Initial Therapy Requirements

    Initial therapy requirements

    Initial coverage considerations

    Preferred biosimilar trial: Patient must have tried and failed BOTH bevacizumabawwb (Mvasi) AND bevacizumab-bvzr (Zirabev) before coverage of other bevacizumab products is considered (e.g., intolerance or inadequate response), unless clinical evidence or patient history indicates such use would be ineffective or harmful.

    Not applicable to intravitreal use.

    Step Therapy Requirements

    StepRequirementFailure criteria
    1Patient must try and fail BOTH bevacizumabawwb (Mvasi) AND bevacizumab-bvzr (Zirabev) before non-preferred bevacizumab products will be considered for coverageFailure defined as intolerance or inadequate response; exception if clinical evidence or patient history indicates these products would be ineffective or cause an adverse reaction

    Biosimilar Preferences and Notes

    Prior Authorization

    Required trial of preferred biosimilars before Avastin (bevacizumab)

    Patient must have tried and failed both bevacizumabawwb (Mvasi) and bevacizumab-bvzr (Zirabev) (for example, intolerance or inadequate response) before coverage of Avastin (bevacizumab) or other non-preferred bevacizumab products will be considered, unless clinical evidence or patient history indicates those products would be ineffective or cause an adverse reaction.

    • Applies to coverage consideration of Avastin (bevacizumab) and other non-preferred bevacizumab products (Alymsys, Avzivi, Jobevne, Vegzelma).
    • Not applicable to intravitreal use.
    Denial Risk

    Avastin (bevacizumab) treated as non-preferred until Mvasi and Zirabev tried and failed

    Bevacizumab (Avastin) is considered a non-preferred product for which coverage will be considered only after the patient has tried and failed BOTH preferred biosimilars bevacizumabawwb (Mvasi) and bevacizumab-bvzr (Zirabev), unless clinical evidence or patient history shows those biosimilars would be ineffective or harmful.

    • This try-and-fail requirement derives from the Patient Selection Criteria and the policy listing of Avastin alongside other non-preferred bevacizumab products.
    • Exception: not applicable to intravitreal use.

    Provider Actions and Authorization Requirements

    Billing Rule

    Prior authorization required for listed HCPCS codes

    Prior authorization is required for all codes listed on this Medical Policy; example HCPCS codes include J3490, J3590, J9035, Q5126, Q5129, and Q5160.

    • Example HCPCS: J3490, J3590, J9035, Q5126, Q5129, Q5160
    Step Therapy

    Required trial of preferred biosimilars (Mvasi and Zirabev)

    Patient must have tried and failed both bevacizumabawwb (Mvasi) and bevacizumab-bvzr (Zirabev) (e.g., intolerance or inadequate response) before coverage of other bevacizumab products will be considered, unless clinical evidence or patient history indicates those products would be ineffective or cause an adverse reaction.

    • Failure can be intolerance or inadequate response.
    • Not applicable to intravitreal use.
    Documentation Required

    Transition authorization documentation required

    When honoring a prior plan's authorization for an ongoing course of treatment during a member transition, documentation of the previous plan's authorization must be provided.

    • Blue Advantage may honor the previous authorization for a 90-day transition period if documentation is provided and the service is otherwise covered.
    Denial Risk

    Denial risk: non-preferred bevacizumab without required biosimilar trials

    Use of non-preferred bevacizumab products (Avastin, Alymsys, Avzivi, Jobevne, Vegzelma) is considered not medically necessary when the patient has not tried and failed BOTH preferred biosimilars (Mvasi and Zirabev).

    • Non-preferred products named: Avastin, Alymsys, Avzivi, Jobevne, Vegzelma.
    • Exception if clinical evidence or patient history indicates Mvasi and Zirabev would be ineffective or cause adverse reaction.
    Denial Risk

    Prior authorization required — potential denial if not obtained

    All codes listed on the Medical Policy require prior authorization; services provided without the required authorization may be denied.

    Coding and Diagnosis Codes

    Codes associated with this policy (examples)HCPCS
    J3490No description provided in policy
    J3590No description provided in policy
    J9035No description provided in policy
    Q5126No description provided in policy
    Q5129No description provided in policy
    Q5160No description provided in policy
    ICD-10 DiagnosisICD-10
    All related diagnosesICD-10 diagnosis codes related to indications

    Background

    Bevacizumab is an anti‑VEGF monoclonal antibody approved for multiple oncologic indications per product labeling; several biosimilar versions of the reference product (Avastin) are available. Biosimilars are biological products that are highly similar to an FDA‑approved reference product with no clinically meaningful differences in safety or effectiveness. This policy reflects preferential use of selected biosimilars (Mvasi and Zirabev) as first‑line options, with coverage of other bevacizumab products contingent on documented failure or intolerance to those preferred agents.

    Definitions

    Biosimilar — definition
    DefinitionBiosimilar: a biological product highly similar to and with no clinically meaningful differences from an FDA‑approved reference product (Avastin is the reference for bevacizumab biosimilars).
    Reference productAvastin (bevacizumab) is identified in the policy as the FDA‑approved reference product for bevacizumab biosimilars.
    Examples of bevacizumab biosimilarsMvasi (bevacizumabawwb), Zirabev (bevacizumab‑bvzr), Alymsys (bevacizumab‑maly), Avzivi (bevacizumab‑tnjn), Jobevne (bevacizumab‑nwgd), Vegzelma (bevacizumab‑adcd).
    Clinical implicationBiosimilars have been determined to have no clinically meaningful differences from the reference product, supporting their use as therapeutic alternatives when coverage criteria are met.
    Policy Summary
    Payerblue cross blue shield - louisiana
    Policybevacizumab Products
    Policy CodePolicy MA-214
    Change TypeNo material changes
    Effective Date07/01/2026
    Last ReviewApr 21, 2026
    Next Review Date04/01/2027
    Key ActionObtain prior authorization and document trial and failure of both preferred biosimilars Mvasi and Zirabev before requesting coverage for non-preferred bevacizumab products.
    SourceLink
    On This Page
    Coverage Criteria for Bevacizumab and BiosimilarsInitial Therapy RequirementsStep Therapy RequirementsBiosimilar Preferences and NotesProvider Actions and Authorization RequirementsCoding and Diagnosis CodesBackgroundDefinitions