CurrentHawaii Medical Service Association (HMSA)Policy N/A

Bevacizumab and biosimilars prior authorization (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev)

Prior authorization form and requirements for bevacizumab and its biosimilars for members whose prescription benefit is administered by CVS Caremark on behalf of HMSA. Applies to providers requesting coverage for these oncology or related indications.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyBevacizumab and biosimilars prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed PA form and supporting documentation to CVS Caremark Specialty Programs via fax to 1-866-237-5512 for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5form criteria question blocks

2preferred biosimilars named

CVSPA administrator

Coverage / Authorization Criteria

Authorization criteria

Coverage/authorization is guided by responses to the following exception and criteria questions:

PA requirement: PA request must include whether drug is for an oncology diagnosis (if No, no further questions).

based on Exception Criteria question A

Product selection and preference: Specify requested product (Alymsys, Avastin, Vegzelma, Mvasi, Zirabev); plan prefers Mvasi or Zirabev. If patient can be switched to a preferred product, follow the indicated skip to Criteria Questions. If claiming intolerance to both preferred products, attach supporting chart notes.

based on Exception Criteria questions B, C and follow-up intolerance question

Clinical indication and supporting data: Provide the patient's diagnosis and ICD-10 code and attach relevant supporting documentation; list or describe all agents in the oncology regimen (single agent or multiple agents).

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyBevacizumab and biosimilars prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed PA form and supporting documentation to CVS Caremark Specialty Programs via fax to 1-866-237-5512 for review.

SourceLink

On This Page

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based on Criteria Questions 1 and 2 and question 8

Regulatory or guideline support: Confirm whether the medication/regimen is prescribed for an FDA‑approved indication or an indication supported by NCCN with a 1 or IIA recommendation (Yes/No).

based on Criteria Question 5

Contraindication check: Confirm whether the patient has a contraindication to the requested medication(s) as listed in the prescribing information; document and attach evidence if present.

based on Criteria Question 6

Prior authorization history: Indicate whether the single agent or entire regimen was previously authorized by HMSA/CVS for this member (Yes/No/Unknown). If No or Unknown, no further questions may be necessary.

based on Criteria Question 7

Treatment benefit documentation: Provide evidence that the patient is benefitting from treatment (positive clinical response or lack of disease progression); attach current clinical documentation (office visit notes, applicable studies). If No, no further questions.

based on Criteria Question 8

The prior authorization form first asks whether the requested drug is being used for an oncology diagnosis. If the response is No, the form indicates no further questions on this form, directing the request to an alternate review path. This step separates oncology uses (which require the full set of regimen and diagnosis questions) from non-oncology requests.

Provider Submission Instructions & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required by the patient’s benefit plan for certain bevacizumab products (including Avastin and biosimilars). Failure to obtain prior authorization may result in noncoverage.

CVS Caremark administers the prescription benefit — send PA and supporting documentation to CVS Caremark Specialty Programs via fax: 1-866-237-5512.
If you have questions regarding the PA, contact CVS Caremark at 1-808-254-4414.

Documentation Required

Submission Instructions

Submit the completed prior authorization form and include the required supporting documentation listed below. Fax to CVS Caremark Specialty Programs: 1-866-237-5512.

Completed HMSA/CVS Caremark prior authorization form.
Attach relevant diagnosis documentation including ICD-10 code(s).
Attach supportive clinical data: treatment notes, office visit notes, and applicable studies.
Attach chart notes documenting intolerable adverse events or contraindications when asserting intolerance or contraindication to preferred biosimilars (Mvasi and Zirabev).
If claiming the patient can be switched to a preferred product, document whether the patient can be switched to Mvasi or Zirabev and provide supporting rationale and chart notes.

Documentation Required

Required Supporting Documentation

Provide documentation that addresses the exception and criteria questions on the PA form.

List or describe all agents in the oncology regimen (single agent or multiple agents).
Provide the patient’s diagnosis and ICD-10 code — attach relevant supportive data.
Indicate whether the requested regimen is for an FDA‑approved indication or an NCCN‑supported indication (Category I or IIA) and attach supporting references when applicable.
Document any contraindication to the requested medication as listed in the prescribing information; if claiming contraindication, attach chart notes.
If prior authorization was previously obtained for this member, indicate yes/no/unknown and attach prior authorization details if available.
For continuation/renewal requests, attach current clinical documentation demonstrating benefit from treatment (positive clinical response or lack of disease progression).
When stating intolerance to preferred products (Mvasi and Zirabev), attach chart notes documenting the intolerable adverse events and indicate whether the adverse event is an expected adverse reaction to the active ingredient per prescribing information.

Clinical Background

Bevacizumab and its biosimilars are managed on this PA form for oncology indications. The form requires confirmation that the medication is being used for an oncology diagnosis, requests the ICD-10 diagnosis code, and asks for a complete list of agents in the oncology regimen. It also requires documentation that the regimen is for an FDA‑approved indication or an indication supported by NCCN with a 1 or IIA recommendation, and asks for clinical evidence of benefit (for example, office visit notes or applicable studies) when applicable.

Preferred Products

Preferred biosimilars identified

Preferred biosimilarsMvasi and Zirabev are identified as the preferred products for the member's health plan.

Action if switch possibleIf the patient can be switched to Mvasi or Zirabev, the form directs to skip to the Criteria Questions.

If not switchableIf the patient cannot be switched to a preferred product, the form asks whether there is a documented intolerable adverse event to both Mvasi and Zirabev; supporting chart notes must be attached if 'Yes'.

Expected adverse event checkThe form asks whether the documented intolerable adverse event is an expected adverse event attributed to the active ingredient per prescribing information; if 'No', attach supporting chart notes.

Step Therapy / Preferred Product Requirements

Step	Requirement	Action / Documentation
1	If patient's treatment can be switched to a preferred biosimilar	Plan prefers Mvasi or Zirabev; select the preferred product on the form (Mvasi or Zirabev) and follow the Criteria Questions.
2	If patient cannot be switched to a preferred biosimilar	Document a documented intolerable adverse event to both Mvasi and Zirabev and attach supporting chart notes (ACTION REQUIRED).
3	If intolerable adverse events are not expected adverse events attributed to the active ingredient	Attach supporting chart notes explaining why the event was not an expected adverse reaction as described in the prescribing information.

Dispense / Administration Site

Note

Specify drug dispense and administration site

Indicate where the drug will be dispensed and where it will be administered on the form by selecting the appropriate site of care.

Dispensed at: office, outpatient hospital, ambulatory surgical, pharmacy, inpatient, or other listed settings
Administered at: office, outpatient hospital, ambulatory surgical, home, inpatient hospital, or pharmacy

Biosimilar Products

Billing Rule

Mvasi listed as preferred — confirm if patient can be switched

Mvasi is listed as a preferred biosimilar product; the form asks whether the patient's treatment can be switched to Mvasi.

If answer is 'Yes, Mvasi' the form directs to skip to Criteria Questions

Billing Rule

Zirabev listed as preferred — confirm if patient can be switched

Zirabev is listed as a preferred biosimilar product; the form asks whether the patient's treatment can be switched to Zirabev.

If answer is 'Yes, Zirabev' the form directs to skip to Criteria Questions