Modifiedculinary health fundPolicy N/A

Bevacizumab (Avastin and biosimilars) Utilization Management — Coverage Criteria

Defines prior authorization, coverage criteria, dosing, and approval durations for bevacizumab injectable products for oncology and selected ophthalmic indications affecting prescribers and payers.

Policy Summary

Payerculinary health fund

PolicyBevacizumab (Avastin and biosimilars) Utilization Management — Coverage Criteria

Policy CodePolicy N/A

Change TypeCriteria revisions and product addition

Effective DateN/A

Next Review DateFeb 25, 2026

Key ActionSubmit prior authorization with documentation that the patient meets the indication‑specific criteria and dosing; ensure an oncologist prescribes or concurs.

SourceLink

POLICY UPDATE CHANGES

Hepatocellular carcinoma criteria were revised to remove prior wording and to add options clarifying unresectable disease and transplant candidacy and Child-Pugh class A or B.

Non-small cell lung cancer criteria were updated to clarify actionable mutation handling (KRAS G12C removed as actionable) and to add NRG1 as an option.

Jobevne (bevacizumab-nwgd) product was added to the policy with the same criteria as other bevacizumab products.

Hepatocellular carcinoma criteria: removed requirement that patient has unresectable or metastatic disease or is not a surgical candidate; added Child-Pugh Class B as acceptable; added and later modified multiple options regarding unresectable disease, transplant candidacy, liver-confined disease, and approval duration.

Non-small cell lung cancer (NSCLC) criteria: changes to how actionable mutations are handled including removing KRAS G12C as actionable and later removing that note; adding NRG1 as an actionable mutation option; removing RET rearrangement from first-line options and adding it for subsequent therapy with additional targeted therapy notes; removal of a requirement re: recent hemoptysis and modification of disease description from non-squamous NSCLC to recurrent/advanced/metastatic disease.

Pediatric medulloblastoma and neurofibromatosis type 2 vestibular schwannomas added as new options for approval under CNS tumors.

Approval duration for hepatocellular carcinoma was changed repeatedly: at one point changed from 1 year to variable 'duration noted', later set to 1 year and other related 1-year options removed.

Small bowel adenocarcinoma dosing regimens updated: added 5 mg/kg IV every 2 weeks as an approval dosing option and modified prior 7.5 mg/kg/2-week frequency to 7.5 mg/kg every 3 weeks.

Soft tissue sarcoma criteria broadened from 'patient has angiosarcoma or solitary fibrous tumor' to 'patient has ONE of the following: Angiosarcoma or ...' (continued modification).

Vaginal cancer added as a new condition of approval; vulvar cancer criteria revised to remove requirement that bevacizumab be used in combination with chemotherapy.

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Recommended Authorization and Indication Criteria

Indication-specific authorization criteria

Coverage of bevacizumab is recommended when the patient meets the listed indication-specific criteria and dosing.

Central Nervous System Tumors (FDA): Approve for 1 year if ALL criteria A-D are met

A: Patient is ≥ 18 years of age; B: Patient has tried at least one previous therapy (examples: temozolomide, etoposide, carmustine, radiotherapy); C: Patient has ONE of: anaplastic gliomas; astrocytoma; glioblastoma; intracranial or spinal ependymoma (excluding subependymoma); meningiomas; oligodendroglioma; medulloblastoma; neurofibromatosis type 2 vestibular schwannomas; OR symptoms due to radiation necrosis, brain edema, or mass effect; D: prescribed by or in consultation with an oncologist; Dosing: 10 mg/kg IV every 2 weeks.

Cervical Cancer (FDA): Approve for 1 year if ALL criteria A-C are met

A: Patient is ≥ 18 years of age; B: Patient has recurrent or metastatic disease OR persistent, recurrent, or metastatic small cell neuroendocrine carcinoma of the cervix; C: prescribed by or in consultation with an oncologist; Dosing: 15 mg/kg IV every 3 weeks.

Colon, Rectal, or Appendiceal Cancer (FDA): Approve for 1 year if ALL criteria A-D are met

A: Patient is ≥ 18 years of age; B: recurrent, advanced, or metastatic disease; C: used in combination with a chemotherapy regimen (examples: 5-FU/leucovorin ± oxaliplatin or irinotecan; capecitabine ± oxaliplatin); D: prescribed by or in consultation with an oncologist; Dosing: one of 5 mg/kg IV q2wk OR 10 mg/kg IV q2wk OR 7.5 mg/kg IV q3wk.

Hepatocellular Carcinoma (FDA): Approve for 1 year if ALL criteria A-D are met

A: Patient is ≥ 18 years of age; B: Patient meets ONE of: (i) medication used as subsequent therapy; OR (ii) medication used for first-line therapy AND prescriber attests the patient has ONE of: (1) liver‑confined, unresectable disease and is ineligible for transplant; OR (2) extrahepatic/metastatic disease and is ineligible for resection, transplant, or locoregional therapy; C: used in combination with atezolizumab (Tecentriq); D: prescribed by or in consultation with an oncologist; Dosing: 15 mg/kg IV every 3 weeks.

Non-Small Cell Lung Cancer (FDA): Approve for 1 year if ALL criteria A-C are met

A: Patient is ≥ 18 years of age; B: patient has recurrent, advanced, or metastatic disease; C: prescribed by or in consultation with an oncologist; Dosing: 15 mg/kg IV every 3 weeks.

Ovarian, Fallopian Tube, or Primary Peritoneal Cancer (FDA): Approve for 1 year if BOTH A and B are met

A: Patient is ≥ 18 years of age; B: prescribed by or in consultation with an oncologist; Dosing: up to 15 mg/kg IV q3wk OR 10 mg/kg IV q2wk depending on regimen.

Renal Cell Carcinoma (FDA): Approve for 1 year if ALL A-C are met

A: Patient is ≥ 18 years of age; B: relapsed, metastatic, or stage IV disease; C: prescribed by or in consultation with an oncologist; Dosing: 10 mg/kg IV every 2 weeks.

Selected Other Uses with Supportive Evidence: Approve for 1 year if the listed criteria for each condition are met

Includes: Ampullary adenocarcinoma (intestinal type; with chemotherapy; dosing 7.5 mg/kg IV q3wk); Endometrial carcinoma (recurrent/advanced/metastatic; dosing up to 15 mg/kg IV q3wk); Mesothelioma (pleural/peritoneal/pericardial/tunica vaginalis testis; with chemo or with atezolizumab; dosing 15 mg/kg IV q3wk); Pediatric CNS tumors (pediatric diffuse high‑grade glioma or medulloblastoma, recurrent/progressive; dosing 10 mg/kg IV q2wk); Small bowel adenocarcinoma (advanced/metastatic with chemo; dosing 5 mg/kg IV q2wk OR 7.5 mg/kg IV q3wk); Soft tissue sarcoma (angiosarcoma or solitary fibrous tumor; dosing up to 15 mg/kg IV q2wk); Vaginal and Vulvar cancers (advanced/recurrent/metastatic; dosing 15 mg/kg IV q3wk).

Indication-specific coverage (history-informed)

Coverage is provided when the patient meets the policy's indication-specific criteria as described in the full policy; history records multiple modifications to those criteria.

Indication-specific criteria: Coverage contingent on meeting the current indication-specific requirements (HCC, NSCLC, CNS tumors, small bowel adenocarcinoma, soft tissue sarcoma, vaginal/vulvar cancer, etc.) as revised in history

Policy history documents revisions including HCC eligibility and duration changes, NSCLC actionable mutation handling (KRAS G12C removed then modified, NRG1 added), small bowel adenocarcinoma dosing updates, addition of biosimilar Jobevne, and other indication-specific modifications.

Requests for bevacizumab that do not meet one of the Recommended Authorization Criteria are not recommended for approval. The policy maintains that coverage should be limited to the specific, indication-based criteria and dosing regimens listed in the Recommended Authorization Criteria and will be updated as new published data become available.

Policy history shows that earlier specific options and notes have been removed or modified for certain indications. Examples include the removal of some previously provided 1‑year approval options for hepatocellular carcinoma and changes to first‑line/subsequent therapy options and mutation‑specific notes for non‑small cell lung cancer. Providers should verify current eligibility and duration options against the active policy language when submitting prior authorization requests.

Review of the policy history indicates that several prior requirements were eliminated or reworded rather than being replaced by explicit “not medically necessary” statements. For example, hepatocellular carcinoma and NSCLC criteria were revised to change or remove prior eligibility conditions (child‑Pugh status, prior systemic therapy, certain actionable mutation notes), reflecting modifications in operational criteria rather than standalone NMN declarations.

Approved Regimens and Combination Therapies

Indication	Permitted Combination / Regimen	Dosing options	Coverage
Colon, rectal, or appendiceal cancer
In combination with intravenous fluorouracil‑based chemotherapy or with fluoropyrimidine‑irinotecan/oxaliplatin regimens (examples: 5‑fluorouracil with leucovorin ± oxaliplatin or irinotecan; capecitabine ± oxaliplatin)
One of: 5 mg/kg IV every 2 weeks; OR 10 mg/kg IV every 2 weeks; OR 7.5 mg/kg IV every 3 weeks
covered

Indication	Permitted Combination / Regimen	Dosing	Coverage
Hepatocellular carcinoma (unresectable or metastatic per prescriber eligibility)
Used in combination with atezolizumab (Tecentriq) per prescriber documentation of eligibility (subsequent therapy OR first‑line with specified liver disease scenarios such as liver‑confined unresectable disease with transplant ineligibility or extrahepatic/metastatic disease ineligible for resection/transplant/locoregional therapy)
15 mg/kg IV every 3 weeks
covered

Indication	Context / regimen	Dosing options (updated)	Coverage
Small bowel adenocarcinoma (advanced/metastatic; used in combination with chemotherapy)
Used with combination chemotherapy per indication criteria
5 mg/kg IV every 2 weeks; OR 7.5 mg/kg IV every 3 weeks (7.5 mg/kg q2w previously modified)
covered

Product	Notes / Criteria	Dosing (per indication)	Coverage
Jobevne (bevacizumab‑nwgd)
Added to covered bevacizumab products; follows the same indication‑specific criteria and documentation requirements as other bevacizumab products
Dosing as specified by the applicable indication (see indication‑specific dosing lines)
covered

Covered Products and Codes

Covered bevacizumab products (by brand/biosimilar)mixedCovered

Avastin	bevacizumab intravenous infusion - Genentech
Alymsys	bevacizumab-maly intravenous infusion - Amneal
Jobevne	bevacizumab-nwgd intravenous infusion - Biocon
Mvasi	bevacizumab-awwb intravenous infusion - Amgen
Vegzelma	bevacizumab-adcd intravenous infusion - Celltrion
Zirabev	bevacizumab-bvzr intravenous infusion - Pfizer

Prior Authorization, Documentation, and Prescriber Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for medical benefit coverage of bevacizumab products when used for non-ophthalmic indications. Approval is recommended when the patient meets the disease-specific Criteria and Dosing in this policy. All requests must document the line/sequence of therapy (e.g., first-line vs subsequent therapy) and supporting clinical history demonstrating prior therapies tried when the criteria require prior therapy. Failure to meet the revised, disease-specific eligibility requirements (for example HCC, CNS tumors, NSCLC, and other conditions listed in the Recommended Authorization Criteria) may result in denial of the request.

Prior authorization required for non-ophthalmic bevacizumab products.
Document line-of-therapy (first-line vs subsequent) for conditions where sequence matters.
If criteria require prior therapy (e.g., CNS tumors), include medication names, dates, and response (examples: temozolomide, etoposide, carmustine, radiotherapy).
Requests not meeting the listed Criteria and Dosing are at risk for denial.

Line-of-Therapy Rules

first-line | second-line | salvage

Line of therapy: Policy permits use as first-line, subsequent (second-line), or salvage therapy depending on the indication and documented clinical scenario

Example: HCC may be used as subsequent therapy OR as first‑line when prescriber documents specific liver disease scenarios and used with atezolizumab; colon cancer supports first- or second-line use in combination with fluorouracil‑based regimens.

first-line | second-line distinctions

First-line | Second-line distinctions: Use in colorectal cancer: permitted in combination with IV fluorouracil‑based chemotherapy for first‑ or second‑line treatment; second‑line allowed after progression on a first‑line bevacizumab‑containing regimen

Refer to indication-specific dosing and combination regimen requirements.

first-line | subsequent

Biomarker and Actionable Mutation Notes

inv-21: KRAS G12C — actionable mutation status

Policy stance on KRAS G12CKRAS G12C is not considered an actionable mutation for NSCLC-targeted therapy decisions (the tumor may be KRAS G12C mutation positive)

Context of changeThis note was added to clarify that KRAS G12C should not be used as an actionable mutation for first-line targeted therapy determination in NSCLC

Implication for testingPresence of KRAS G12C alone does not satisfy 'actionable mutation' criteria for first-line bevacizumab-related NSCLC decisions per the history entry

inv-22: KRAS G12C — history duplicate reference

Duplicate/history referenceKRAS G12C actionable-mutation note appears in the policy history across revisions (added/removed in NSCLC criteria)

Revision timeline

Key Definitions

inv-16: Bevacizumab definition

DefinitionBevacizumab is a recombinant humanized monoclonal antibody that binds to and inhibits the biologic activity of human vascular endothelial growth factor (VEGF)

MechanismInhibits VEGF, a key mediator of angiogenesis

Clinical use noteUsed in multiple oncology indications as described in the policy (see indication-specific criteria for dosing and authorization)

inv-17: Actionable mutation — definition and history note

Actionable mutation — definitionMutations or rearrangements used to determine targeted therapy options; examples and which mutations are considered actionable have changed across policy history

Evolution example 1KRAS G12C was specifically noted as NOT considered actionable in an earlier revision and later that specific note was removed

Background and Scope

Bevacizumab is a recombinant humanized monoclonal antibody that binds to and inhibits vascular endothelial growth factor (VEGF), reducing tumor angiogenesis and limiting blood supply to tumors. The policy covers multiple FDA‑approved oncology indications and additional uses supported by evidence; use generally requires documentation of the specific indication and dosing regimen and involvement of an oncology prescriber. Policy history entries document indication‑specific changes (for example, hepatocellular carcinoma and non‑small cell lung cancer) that affect eligibility and dosing and should be reviewed when evaluating requests for coverage.