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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsCDPHP Avastin Prior Auth Coverage | OpenPayer
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    CurrentCapital District Physicians' Health Plan (CDPHP)Policy N/A

    Medicaid Coverage Policy for Avastin (bevacizumab) Solution for Injection

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    This policy governs Medicaid coverage and prior authorization for Avastin (bevacizumab) injection for specified oncology indications and treatment regimens, subject to failure of specified bevacizumab biosimilar therapy.

    Policy Summary
    PayerCapital District Physicians' Health Plan (CDPHP)
    PolicyMedicaid Coverage Policy for Avastin (bevacizumab) Solution for Injection
    Policy CodePolicy N/A
    Change TypeNo material clinical or coverage changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit prior authorization requests after documenting failure of two bevacizumab biosimilar agents for at least 6 months due to qualifying adverse reactions.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    8Covered oncology indications
    2Listed biosimilars
    6 monthsMinimum treatment duration
    2Biosimilar agents required to fail
    2
    Policy Summary
    PayerCapital District Physicians' Health Plan (CDPHP)
    PolicyMedicaid Coverage Policy for Avastin (bevacizumab) Solution for Injection
    Policy CodePolicy N/A
    Change TypeNo material clinical or coverage changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit prior authorization requests after documenting failure of two bevacizumab biosimilar agents for at least 6 months due to qualifying adverse reactions.
    SourceLink
    On This Page
    Avastin Coverage CriteriaCovered Diagnoses and Billing CodesAuthorization and Documentation RequirementsPolicy BackgroundInitial Avastin AuthorizationBiosimilar Step TherapyVial Strengths and Quantity InformationFDA-Approved Bevacizumab Biosimilars

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Vial strengths listed

    Avastin Coverage Criteria

    Initial Avastin Therapy

    Coverage requires all of the following:

    Avastin prior authorization criteria

    • Prior authorization: Avastin (bevacizumab) requires prior authorization.

    • Biosimilar treatment failure

      • Biosimilar agents: Treatment has failed with Zirabev (bevacizumab-bvzr) and Mvasi (bevacizumab-awwb), or applicable new FDA-approved biosimilar market entrants.At least 6 months of treatment

        Document the intolerable or significant adverse reaction attributed to the active ingredient for each product.

      • Adverse reaction attribution: The adverse reactions are documented, intolerable or significant, not expected, and attributed to the active ingredient described in the prescribing information.Documented intolerable/significant reaction

    Covered Diagnoses and Billing Codes

    Covered ICD-10 CodesICD-10Covered
    C18.0ICD10 diagnosis code listed in the policy
    C18.1ICD10 diagnosis code listed in the policy
    C18-2-C18.9ICD10 diagnosis code range listed in the policy
    C19ICD10 diagnosis code listed in the policy
    C20ICD10 diagnosis code listed in the policy
    C21.8ICD10 diagnosis code listed in the policy
    C33ICD10 diagnosis code listed in the policy
    C34.00-C34.02ICD10 diagnosis code range listed in the policy
    C34.10-C34.12ICD10 diagnosis code range listed in the policy
    C34.2ICD10 diagnosis code listed in the policy
    1–10 of 26
    1/3
    Covered HCPCS CodesHCPCSCovered
    J9035Avastin (bevacizumab) HCPCS code
    Q5118Zirabev (bevacizumab-bvzr) biosimilar HCPCS code
    Q5107Mvasi (bevacizumab-awwb) biosimilar HCPCS code
    Covered NDC CodesNDCCovered
    50242-0060-01Single-dose vial 100 mg/4 mL NDC
    50242-0061-01Single-dose vial 400 mg/16 mL NDC
    Biosimilar Treatment Duration
    Minimum treatment durationAt least 6 months
    Applies toBevacizumab biosimilar treatment before Avastin coverage
    Failure basisDocumented intolerable or significant adverse reactions attributed to the active ingredient
    Biosimilar Treatment Failure
    Required agents failedTwo bevacizumab biosimilar agents
    Listed biosimilarsZirabev (bevacizumab-bvzr) and Mvasi (bevacizumab-awwb)

    Authorization and Documentation Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for Avastin (bevacizumab). Submit the request with documentation demonstrating that the applicable clinical criteria are met.

    Step Therapy

    Biosimilar-First Requirement

    Avastin coverage requires failure of both listed bevacizumab biosimilar agents for at least 6 months because of documented intolerable or significant adverse reactions.

    • Zirabev (bevacizumab-bvzr), HCPCS Q5118
    • Mvasi (bevacizumab-awwb), HCPCS Q5107
    Documentation Required

    Policy Background

    Avastin (bevacizumab) is covered for selected oncology indications, including metastatic colorectal cancer, non-squamous non-small cell lung cancer, metastatic renal cell carcinoma, cervical cancer, and epithelial ovarian, fallopian tube, or primary peritoneal cancers. Coverage also includes recurrent glioblastoma in adults. For most solid-tumor indications, Avastin is used in combination with specified chemotherapy or biologic regimens; some ovarian, fallopian tube, and primary peritoneal cancer regimens continue with Avastin monotherapy after combination treatment.

    Initial Avastin Authorization

    Initial Avastin Authorization

    Initial Avastin therapy requires prior authorization and satisfaction of the biosimilar failure criterion.

    Initial Avastin authorization

    • Prior authorization is obtained for Avastin (bevacizumab).
    • Biosimilar treatment failure: The enrollee has failed treatment with two bevacizumab biosimilar agents for at least 6 months due to documented intolerable or significant adverse reactions attributed to the active ingredient.Two biosimilars; at least 6 months

      Expected adverse reactions to the active ingredient do not satisfy the criterion; new FDA-approved biosimilar market entrants apply.

    Biosimilar Step Therapy

    StepRequirementBiosimilar agentsDurationFailure criteria
    1Fail treatment with two bevacizumab biosimilar agents before Avastin coverage.Zirabev (bevacizumab-bvzr; Q5118) and Mvasi (bevacizumab-awwb; Q5107)At least 6 monthsDocumented intolerable or significant adverse reactions that are not expected and are attributed to the active ingredient described in the prescribing information.

    Vial Strengths and Quantity Information

    Avastin Quantity Limit
    DrugAvastin (bevacizumab)
    Vial strengthSingle-dose vial 100 mg/4 mL
    NDC50242-0060-01
    UnitVial per course
    Avastin Quantity Limit
    DrugAvastin (bevacizumab)
    Vial strengthSingle-dose vial 400 mg/16 mL

    FDA-Approved Bevacizumab Biosimilars

    Billing Rule

    Document failure of Zirabev

    Zirabev (bevacizumab-bvzr) is one of the listed FDA-approved bevacizumab biosimilars that must be failed before Avastin coverage. Report HCPCS code Q5118 when documenting the biosimilar trial.

    • Zirabev (bevacizumab-bvzr) — Q5118
    Billing Rule

    Document failure of Mvasi

    Mvasi (bevacizumab-awwb) is one of the listed FDA-approved bevacizumab biosimilars that must be failed before Avastin coverage. Report HCPCS code Q5107 when documenting the biosimilar trial.

    • Mvasi (bevacizumab-awwb) — Q5107
    Coverage requirementBoth agents must be failed before Avastin coverage

    Document Biosimilar Treatment Failure

    Document the treatment duration and the intolerable or significant adverse reactions for each biosimilar trial. The reactions must be unexpected and attributed to the active ingredient, consistent with adverse reactions described in the prescribing information for both brand and biosimilar products.

    • Document at least 6 months of treatment with each biosimilar.
    • Identify the specific intolerable or significant adverse reaction for each product.
    Denial Risk

    Failure to Meet Biosimilar Trial Requirement

    Coverage may be denied when the required trials of both biosimilars have not been completed for at least 6 months or when the record does not document qualifying treatment failure and adverse reactions.

    • Failure to try both Zirabev and Mvasi.
    • Treatment duration of less than 6 months for either biosimilar.
    • Missing or insufficient documentation of intolerable or significant adverse reactions.
    Denial Risk

    Use a Policy-Supported Indication

    Coverage may be denied for an indication, treatment regimen, or diagnosis outside those specified in the policy. Ensure the request identifies a policy-supported Avastin indication and the corresponding diagnosis and regimen.

    • Policy-supported indications include specified colorectal, non-squamous non-small cell lung, glioblastoma, renal cell, cervical, ovarian, fallopian tube, and primary peritoneal cancer uses.
    • Requests for unlisted indications, regimens, or diagnoses may not meet coverage criteria.
    NDC
    50242-0061-01
    UnitVial per course