EmblemHealth bevacizumab coverage update

Coverage Criteria

Brain Necrosis

Covered when ALL of the following are met for brain necrosis:

Brain necrosis/edema indication: Member has brain necrosis or edema due to cranial irradiation and bevacizumab/bevacizumab biosimilar is being used as monotherapy

Use not recommended in members with intracranial hemorrhage

Cervical Cancer

Covered when ANY of the following first-line regimens are used for metastatic/recurrent/unresectable cervical cancer:

Cervical cancer first-line options: Bevacizumab/bevacizumab biosimilar used in combination with cisplatin or carboplatin plus paclitaxel

Cervical cancer first-line options: Bevacizumab/bevacizumab biosimilar used in combination with topotecan plus paclitaxel

Cervical cancer PD-L1 positive option: Bevacizumab/bevacizumab biosimilar plus pembrolizumab (Keytruda) with cisplatin or carboplatin plus paclitaxel for PD-L1 positive metastatic cervical cancer>=1%

Colorectal Cancer

Covered when ALL of the following apply for unresectable advanced or metastatic colorectal cancer:

Initial therapy: Bevacizumab/bevacizumab biosimilar used as initial therapy in combination with capecitabine, FOLFOX, FOLFIRI, FOLFIRINOX, 5-FU/LV, or CapeOX

Subsequent therapy: Bevacizumab/bevacizumab biosimilar used as subsequent-line therapy in combination with FOLFOX, FOLFIRI, XELIRI, or XELOX/CapeOX

Policy permits use up to 2 lines in the metastatic setting or up to 3 lines when used with trifluridine/tipiracil (Lonsurf)

Glioblastoma / High-grade glioma

Covered for recurrent high-grade gliomas when used as monotherapy or in combination:

Glioblastoma / high-grade glioma: Bevacizumab/bevacizumab biosimilar used as a single agent OR in combination with irinotecan, carboplatin, carmustine, lomustine, or temozolomide for recurrent disease

Hepatocellular Carcinoma (HCC)

Covered for hepatocellular carcinoma in specified settings:

HCC adjuvant high-risk: Bevacizumab/bevacizumab biosimilar in combination with atezolizumab (Tecentriq) as adjuvant therapy in adult members with hepatocellular carcinoma (Child-Pugh Class A) following resection or ablation who are at high risk of recurrence

High risk defined by tumor >5 cm, >3 tumors, macrovascular or microvessel invasion on histology, or Grade 3/4 histology

HCC advanced/metastatic: Bevacizumab/bevacizumab biosimilar plus atezolizumab for initial therapy of metastatic, inoperable, or advanced hepatocellular carcinoma (Child-Pugh Class A)

Non-Small Cell Lung Cancer (NSCLC)

Covered for first-line metastatic non-squamous NSCLC when ALL apply:

NSCLC first-line: Bevacizumab/bevacizumab biosimilar used in combination with atezolizumab, paclitaxel, and carboplatin for metastatic non-squamous NSCLC with no EGFR or ALK genomic tumor aberrations

Certain bevacizumab regimens (e.g., with erlotinib or with carboplatin/pemetrexed followed by maintenance bevacizumab plus pemetrexed) are not supported

Ovarian Cancer

Covered for ovarian cancer in the following settings:

Ovarian initial: Initial/first-line therapy for stage II–IV disease in combination with chemotherapy

Ovarian maintenance: Maintenance therapy after complete or partial response to primary chemotherapy plus bevacizumab/bevacizumab biosimilar: as monotherapy for BRCA wild-type/unknown and HRD negative/unknown, OR in combination with olaparib (Lynparza) for BRCA-mutated or HRD positive disease

Ovarian recurrent: Therapy of relapsed or recurrent ovarian cancer with bevacizumab/bevacizumab biosimilar as monotherapy or in combination with chemotherapy

Bevacizumab and bevacizumab biosimilars are excluded when requested for use on or after documented disease progression on a prior bevacizumab-containing regimen, except as explicitly allowed for colorectal cancer. For colorectal cancer only, bevacizumab may be used for up to 2 lines of therapy in the metastatic setting, or up to 3 lines of therapy when combined with trifluridine/tipiracil (Lonsurf). Requests falling outside these limits will be denied as excluded.

Abstracts, including meeting abstracts, that lack the full peer‑reviewed journal article are not acceptable as sole supporting evidence and are excluded from the evidentiary basis for coverage. In addition, investigational or off‑label uses lacking sufficient evidence per CMS‑recognized compendia or acceptable peer‑reviewed literature (as detailed in the policy’s evidentiary standards) will be excluded.

The lists of procedure codes, services, and drugs provided in this guideline are illustrative and not exhaustive. Inclusion on a list does not by itself indicate that a service or drug is covered or non‑covered; coverage determinations remain subject to the member’s plan terms and applicable prior authorization requirements.

The policy does not support bevacizumab or bevacizumab biosimilars for certain indications based on insufficient Level 1 evidence. Specifically, use in metastatic renal cell carcinoma is not supported. Additionally, several non‑squamous NSCLC regimens that lack randomized trial or meta‑analysis evidence (for example, bevacizumab plus erlotinib, or bevacizumab with carboplatin/cisplatin + pemetrexed followed by maintenance bevacizumab + pemetrexed) are also not supported.

first-line | subsequent

Colorectal lines: Bevacizumab/bevacizumab biosimilar may be used up to 2 lines of therapy in the metastatic colorectal cancer setting; may be used up to 3 lines when given with trifluridine/tipiracil (Lonsurf)

first-line

Cervical initial: Bevacizumab/bevacizumab biosimilar may be used as first-line/initial therapy in the listed cervical cancer regimens

Covered Regimens

Regimen	Indication / Notes	Coverage
Bevacizumab + pembrolizumab (Keytruda) + cisplatin or carboplatin + paclitaxel
Initial treatment for PD-L1 positive metastatic cervical cancer (PD-L1 ≥ 1%)
Covered when PD-L1 ≥ 1% and used as listed first-line regimen

Regimen	Indication / Notes	Coverage
Bevacizumab + atezolizumab + paclitaxel + carboplatin
First-line treatment of adult members with metastatic non-squamous NSCLC with no EGFR or ALK genomic tumor aberrations
Covered when used in first-line for metastatic non-squamous NSCLC and EGFR/ALK aberrations are absent

Regimen	Indication / Notes	Coverage
Bevacizumab + XELIRI
Subsequent therapy option for unresectable advanced or metastatic colorectal cancer
Covered when used as one of the listed combination regimens

Regimen	Indication / Notes	Coverage
Bevacizumab + atezolizumab
Adjuvant therapy for adult members with HCC (Child-Pugh Class A) at high risk of recurrence following resection or ablation; also for initial therapy of metastatic/inoperable/advanced HCC (Child-Pugh Class A)
Covered when used in combination with atezolizumab in the specified HCC settings

Regimen	Indication / Notes	Coverage
Bevacizumab and bevacizumab biosimilars
Use in metastatic renal cell carcinoma is not supported by policy
Not supported / Not covered for metastatic renal cell carcinoma

Coding and Dosing Information

Drug HCPCS/CodesHCPCS

C9257	Injection, bevacizumab, 0.25 mg
J9035	Injection, bevacizumab, 10 mg
Q5107	Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg
Q5118	Injection, bevacizumab-bvzr, biosimilar, (zirabev), 10 mg
Q5126	Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg
Q5129	Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg
J9999	bevacizumab-tnjn
J9999	bevacizumab-nwgd

Maximum single dose — 15 mg/kg

Maximum single dose15 mg/kg

Exclusion if exceededDosing that exceeds the single dose limit of 15 mg/kg is excluded per policy

Regimen-specific lower limitsCertain regimens specify lower maximums (e.g., 5 mg/kg with irinotecan/FOLFIRI/FOLFOX/IROX)

Max doses for brain necrosis — 4 doses (dose range 5 mg/kg q2w to 7.5 mg/kg q3w)

Maximum number of doses (brain necrosis)4 doses maximum

Allowed dose range5 mg/kg every 2 weeks to 7.5 mg/kg every 3 weeks

Indication context

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for bevacizumab products processed by Evolent. Medication requests not authorized by Evolent may be denied and deemed not reimbursable.

Prior authorization required for bevacizumab products processed by Evolent.
Requests not authorized by Evolent may be deemed not approvable and not reimbursable.

Prior Authorization

Prior Authorization and Service Limitations

Prior authorization and service limitations noted in the Evolent Clinical Guideline apply and may be subject to denial if not authorized per the member's plan terms. A list of procedure codes, services, or drugs in the guideline is not exhaustive and does not guarantee coverage; coverage varies by member plan and program.

Prior authorization and service limitations in the guideline may be required by the member's plan.
Coverage varies by individual member plan or government program; check plan terms.

Definitions and Requirements

High risk of recurrence (HCC)

Tumor sizeTumor size > 5 cm

Number of tumorsMore than 3 tumors

Vascular invasion on histologyMacrovascular or microvessel invasion on histology

Histologic gradeGrade 3 or 4 histology

Sufficient evidence — Clinically meaningful outcomes generally follow ASCO recommendations (e.g., hazard ratio <0.80 and OS/PFS benefit)

ASCO definition for clinically meaningful outcomesHazard ratio < 0.80 and recommended survival benefit for OS/PFS ≥ 3 months

Evidence standards

Background

Bevacizumab is a recombinant monoclonal antibody that targets vascular endothelial growth factor (VEGF) to inhibit tumor angiogenesis. It is used across multiple solid tumor indications in oncology and, in select cases, for non‑malignant radiation‑related complications such as radiation‑associated brain necrosis/edema. Evolent aligns permitted uses with FDA labeling, CMS‑recognized compendia, and major oncology guidelines, and applies specific dose, duration, and line‑of‑therapy limits for covered indications.

OpenPayer

Bevacizumab products (Avastin and biosimilars) - Coverage Criteria