ModifiedHealth NetPolicy CP PHAR.93

Bevacizumab (Alymsys, Avastin, Avzivi, Jobevne, Mvasi, Vegzelma, Zirabev) - Coverage Criteria

Defines medical necessity, prior authorization, and approval durations for bevacizumab (Avastin) and listed biosimilars across oncology and certain ophthalmology uses for Health Net lines of business. Applies to providers requesting coverage for these drugs.

Policy Summary

PayerHealth Net

PolicyBevacizumab (Alymsys, Avastin, Avzivi, Jobevne, Mvasi, Vegzelma, Zirabev) - Coverage Criteria

Policy CodePolicy CP PHAR.93

Change TypeIndication updates, biosimilars added, HCPCS coding changes

Effective DateDec 1, 2011

Next Review Date

Key ActionSubmit prior authorization with supporting clinical documentation and, for non-ophthalmology requests, use preferred biosimilars (Mvasi or Zirabev) unless contraindicated.

SourceLink

POLICY UPDATE CHANGES

Added newly FDA-approved biosimilars Avzivi and Jobevne to the policy.

Reorganized and updated multiple oncology indication criteria per NCCN including additions and clarifications for CRC, cervical cancer, RCC, ovarian cancer, HCC, and NSCLC.

Added multiple off-label oncology uses and pediatric non-FDA indications (e.g., diffuse high-grade glioma) and expanded ophthalmology supported uses.

Updated HCPCS/HCPCS-related coding to add Q51261, Q51291 and Vegzelma-related code C9142L RT4 and removed C9142.

Commercial: 12mtypical approval duration

Medicaid/HIM: 6mtypical approval duration

15 mg/kg

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

2.5 mgophthalmology dose cap

HCPCS updatescodes referenced

Avzivi, Jobevnebiosimilars added

Coverage Criteria

inv-01: Initial Therapy and Indication-Specific Criteria

Covered when ALL of the following are met for Initial Approval (oncology and specified uses):

Initial Approval core requirements: Provider must submit documentation (office chart notes, lab results, or other clinical information) demonstrating the member meets all approval criteria; prescribed by or in consultation with an oncologist for oncology uses (ophthalmology uses require an ophthalmologist); age > 18 years for adult oncology indications unless pediatric criteria apply.

See indication-specific nodes

Diagnoses: Diagnosis must be one of the listed FDA-approved indications: metastatic colorectal cancer (CRC), unresectable/locally advanced/recurrent/metastatic non-squamous NSCLC, recurrent glioblastoma, persistent/recurrent/metastatic cervical cancer, metastatic renal cell carcinoma (relapsed or metastatic), epithelial ovarian/fallopian tube/primary peritoneal cancer, or hepatocellular carcinoma (HCC) in combination with atezolizumab (Tecentriq).

See chunks 7-9

Regimen-specific requirements for CRC: Disease is advanced, metastatic, or unresectable AND bevacizumab is prescribed in combination with an appropriate chemotherapy regimen (examples: 5-FU/leucovorin or capecitabine-based regimens; FOLFOX or CapeOX; irinotecan or FOLFIRI; IROX; FOLFIRINOX; Lonsurf if previously progressed through available regimens).

chunk 7; dosing details in chunk 35

Regimen-specific requirements for non-squamous NSCLC: Bevacizumab prescribed as single agent or in specified combinations (e.g., with carboplatin+paclitaxel; with pemetrexed ± platinum; with atezolizumab (Tecentriq) ± carboplatin/paclitaxel; or with erlotinib for sensitizing EGFR mutations).

chunk 7

Glioblastoma: For glioblastoma, member has recurrent disease or requires symptom management (recurrent glioblastoma is an FDA‑approved indication).

chunks 7,8

Renal cell carcinoma (RCC): Disease is relapsed or metastatic AND bevacizumab is prescribed as a single agent or in combination (examples: with everolimus; for advanced papillary RCC only, in combination with erlotinib).

chunk 8

Cervical cancer: Disease is persistent, recurrent, or metastatic AND bevacizumab is prescribed as single agent or in specified combinations (e.g., with paclitaxel + cisplatin/carboplatin ± immunotherapy such as atezolizumab/Tecentriq per indication and PD-L1 status).

chunk 8

Ovarian and related cancers: Bevacizumab use covered for epithelial ovarian/fallopian tube/primary peritoneal cancer in specified settings including combination with platinum-based chemotherapy followed by maintenance bevacizumab, maintenance with PARP inhibitors when indicated, and regimens for platinum‑sensitive and platinum‑resistant disease as detailed in the dosing section.

chunk 8; dosing in chunks 36,35

Hepatocellular carcinoma (HCC): For HCC, bevacizumab is covered in combination with atezolizumab (Tecentriq) for unresectable or metastatic disease as first-line systemic therapy and as a subsequent-line systemic therapy option per NCCN guidance when applicable.

chunks 9,36

Biosimilar preference: Member must use preferred biosimilars (Mvasi or Zirabev) for non-ophthalmology oncology requests unless both are contraindicated or clinically significant adverse effects occur; prior authorization may be required for Mvasi and Zirabev and state step-therapy prohibitions may create exceptions.

chunks 9,19

Dose and regimen limits: Dose must not exceed 15 mg/kg IV every 3 weeks or 10 mg/kg IV every 2 weeks for standard IV oncology regimens unless the dose/regimen is supported by FDA labeling, NCCN, or peer-reviewed literature; prescriber must submit supporting evidence for off‑label or above‑limit dosing.<= 15 mg/kg q3w or <= 10 mg/kg q2w

chunks 9,13,35

inv-02: Non-FDA-Approved Oncology Indications

Off-label oncology and pediatric uses (must meet all):

Adult off-label oncology (Section B): Diagnosis must be one of the enumerated off-label adult oncology indications (examples include specified glioma subtypes, endometrial carcinoma, ampullary adenocarcinoma intestinal type, intracranial/spinal ependymoma, peritoneal mesothelioma, pleural mesothelioma, meningioma, medulloblastoma, metastatic spine tumors/brain metastases, small bowel adenocarcinoma, primary CNS lymphoma, solitary fibrous tumor/angiosarcoma, NF2 vestibular schwannomas with hearing loss, vulvar and vaginal cancers). Prescribed by or in consultation with an oncologist; age ≥ 18 years. For requests for non‑preferred brands, member must use Mvasi or Zirabev unless contraindicated or the request is in a state with step therapy prohibitions; prior authorization for Mvasi/Zirabev may be required.

chunks 10-12

Combination therapy requirements for select diagnoses: For specified off-label diagnoses (e.g., ampullary adenocarcinoma, peritoneal mesothelioma, pleural mesothelioma, small bowel adenocarcinoma, vulvar cancer), bevacizumab must be prescribed as part of combination therapy as indicated in the policy.

chunk 11

Single-agent allowance for select diagnoses:

inv-03: Ophthalmology (intravitreal) Uses

Ophthalmology non-FDA-approved indications (must meet all):

Ophthalmology indications: Diagnosis must be one of the supported intravitreal indications (neovascular age-related macular degeneration, macular edema following retinal vein occlusion, diabetic macular edema, proliferative diabetic retinopathy, choroidal neovascularization from any cause, neovascular glaucoma, diabetic retinopathy with ocular neovascularization, or retinopathy of prematurity).

chunk 16

Prescriber and formulation: Bevacizumab must be prescribed by or in consultation with an ophthalmologist AND the request must be for bevacizumab intravitreal solution (requests for IV formulations for ophthalmology uses will not be approved).

chunk 17

Dose limit: Intravitreal dose must not exceed 2.5 mg per dose (typical intravitreal regimens 1–2.5 mg every 4 weeks depending on indication).<= 2.5 mg per dose

chunks 17,38

inv-04: Continued Therapy

Covered when ALL of the following are met for continued therapy

Continued Therapy All Indications: a) Member is currently receiving the medication via the health plan benefit OR previously met initial approval criteria; b) Member is currently receiving medication and is enrolled in a state/product with continuity-of-care regulations when applicable; c) Documentation supports current use of a listed bevacizumab product for a covered oncology indication and the member has received at least 30 days of therapy.30 days

Includes requirement for positive response to therapy for certain non-ophthalmology requests and biosimilar preference rules; see nested nodes

Non-ophthalmology biosimilar preference: For ongoing non-ophthalmology therapy with Alymsys, Avastin, Avzivi, Jobevne, or Vegzelma, member must either be using Mvasi or Zirabev unless both are contraindicated or adverse effects occurred, OR the request is for treatment in a state with regulations prohibiting redirection/step therapy (Appendix E).

chunks 22,23

Dose increase rules: If the request is for a dose increase, the new dose must not exceed 15 mg/kg IV every 3 weeks or 10 mg/kg IV every 2 weeks unless the increase is supported by practice guidelines or peer-reviewed literature and supporting evidence is submitted.

inv-05: Other diagnoses/indications

Covered when condition-specific and policy routing conditions are met

Other diagnoses/indications: For requests involving Alymsys, Avastin, Avzivi, Jobevne, or Vegzelma for non‑ophthalmology uses, the member must either be using a preferred biosimilar (Mvasi or Zirabev) unless both are contraindicated or the request is for treatment in a state with regulations against step therapy/redirection (see Appendix E). If the drug recently had a label change not reflected in this policy, or if the drug is non‑formulary, follow the referenced line-of-business policies; if the requested use is not listed, follow the off‑label use policy for the applicable line of business.

References include specific CP/HIM policies listed in the document (see chunk 19)

inv-06: Dosing and administration by indication

Dosing regimens and maximum doses by indication

Non-squamous NSCLC: 15 mg/kg IV every 3 weeks in combination with carboplatin and paclitaxel; maximum dosing guidance: no greater than 15 mg/kg IV every 3 weeks or 10 mg/kg IV every 2 weeks.Maximum 15 mg/kg q3w or 10 mg/kg q2w

chunk 36

Ovarian cancer (stage III/IV post-resection): 15 mg/kg IV every 3 weeks with carboplatin/paclitaxel for up to 6 cycles, followed by bevacizumab 15 mg/kg q3w as single-agent maintenance; maximum dosing per general guidance.Maximum 15 mg/kg q3w or 10 mg/kg q2w

chunk 36

Platinum-resistant ovarian cancer: 10 mg/kg IV every 2 weeks in combination with weekly paclitaxel, liposomal doxorubicin, or topotecan; maximum dosing per general guidance.

inv-07: Indication-level criteria updates

Coverage and clinical criteria have been updated per NCCN and FDA approvals; specific qualifiers and combination therapy requirements vary by indication.

Indications updated per NCCN and FDA: Multiple oncology indications were revised to align with NCCN and recent FDA biosimilar approvals: CRC clarified as advanced/metastatic/unresectable; cervical cancer updated to allow single-agent and Tecentriq combination options; RCC removed interferon alfa combination; ovarian cancer combination and maintenance criteria simplified and expanded; HCC pathway revisions include adjuvant and subsequent-line options; NSCLC reorganized with unresectable qualifier and EGFR sensitizing-mutation guidance for erlotinib combination; biosimilars Avzivi and Jobevne were added to the policy and HCPCS coding was updated.

See per-indication sections and history chunks 54-58

inv-08: Ophthalmology criteria

Ophthalmology-specific coverage notes

Ophthalmology coverage: Choroidal neovascularization is allowed for any cause; radiation retinopathy and retinopathy of prematurity are supported uses; an ophthalmologist must be the prescriber for intravitreal bevacizumab; age restriction has been removed where pediatric diagnosis supports use; IV formulations for ophthalmology will not be approved.

chunks 56,17,38

Bevacizumab products are explicitly not indicated for adjuvant treatment of colon cancer. This limitation of use is stated in the policy and should be applied when assessing requests for bevacizumab in the adjuvant colorectal cancer setting.

For ophthalmology indications the policy requires use of the intravitreal formulation. Requests for IV formulations of Avastin, Alymsys, Avzivi, Jobevne, Mvasi, Vegzelma, or Zirabev for ophthalmology indications will not be approved, and intravitreal doses must not exceed 2.5 mg per dose.

Non‑FDA‑approved indications that are not specifically addressed in this policy are excluded from coverage unless the provider supplies sufficient documentation of efficacy and safety per the applicable off‑label use policies (e.g., CP.CPA.09 for commercial and HIM.PA.154 for Marketplace). Such documentation must meet the plan’s off‑label evidence requirements to be considered for authorization.

The policy history documents removal of previously listed off‑label uses and other historic changes. Examples include the removal of AIDS‑related Kaposi sarcoma as an off‑label use when NCCN no longer supported it, multiple annual updates aligning indications and regimens with NCCN/FDA changes, and template updates that added or removed HCPCS codes and modified redirection language to preferred biosimilars.

Coverage under this policy is subject to plan‑level exclusions, limitations, and benefit terms. When conflicts exist with Medicaid program rules or state‑specific Medicaid provisions, the state Medicaid requirements supersede this policy. The policy itself does not guarantee payment; adjudication follows the member’s coverage documents and applicable law.

Uses that are non‑FDA approved and are not specifically addressed in this policy are not authorized unless the provider submits sufficient supporting evidence in accordance with the plan’s off‑label use policies. Absent that documentation, requests for non‑listed off‑label uses should be considered not medically necessary.

AIDS‑related Kaposi sarcoma was removed from the list of supported off‑label indications during prior reviews because it is no longer supported by NCCN guidance. As a result, requests for bevacizumab for AIDS‑related Kaposi sarcoma are no longer included as an authorized off‑label use in this policy.

This clinical policy is guideline‑based and intended to aid medical necessity determinations; it does not constitute a contract or guarantee of payment. Coverage decisions remain subject to the member’s benefit documents, state and federal requirements, and Health Plan administrative policies and procedures.

Initial Therapy Criteria

inv-49: Initial therapy requirements

Initial approval criteria for FDA-approved indications

Prescriber: Prescribed by or in consultation with an oncologist for oncology uses; ophthalmology uses must be prescribed by or in consultation with an ophthalmologist.

chunks 7,17

Age: Adult oncology indications: age > 18 years unless pediatric section applies; pediatric indications have separate age-appropriate criteria.

chunks 7,14

Diagnosis and regimen: Diagnosis must be an FDA-approved indication and the prescribed regimen must meet the per-indication criteria (see dosing/admin section) including combination requirements where applicable.

chunks 7,8,36

Continuation and Renewal Criteria

inv-53: Approval duration and continuation

Approval durations and continuation rules

Approval duration: Commercial approvals up to 12 months or duration of request, whichever is less; Medicaid/HIM approvals for 6 months. Continued approvals require documentation of ongoing benefit and adherence to dosing and regimen guidance; doses beyond FDA limits require supporting evidence.Commercial: 12 months; Medicaid/HIM: 6 months

chunks 13,53

inv-54: Continued Therapy

Continuation therapy covered when the following are met:

Continuation criteria: Member is currently receiving therapy or previously met initial approval; member is enrolled in a continuity-of-care state/product when applicable; documentation shows at least 30 days of therapy for a covered oncology indication; member is responding positively to therapy for certain non-ophthalmology requests. Biosimilar preference and dose increase rules apply.

Coding and Dose Limits

Codes referencedmixed

not specified in this segment

No explicit CPT/HCPCS/ICD codes were provided in these chunks.

Referenced HCPCS/CodesHCPCS

C9257
J9035
J9999	Not otherwise classified, antineoplastic drugs
Q5107
Q5118
Q5126	Injection, bevacizumab-maly, biosimilar, (Alymsys) 10 mg
Q5129	Injection, bevacizumab-adcd (Vegzelma) biosimilar, 10 mg

Sample ICD-10 Diagnosis Codes that Support CoverageICD-10Covered

A18.53	Tuberculosis chorioretinitis
C17.0	Malignant neoplasm of small intestine
C18.0	Malignant neoplasm of colon
C19	Malignant neoplasm of rectosigmoid junction
C20	Malignant neoplasm of rectum
C53.0	Malignant neoplasm of cervix uteri
C56.1	Malignant neoplasm of ovary
C64.1	Malignant neoplasm of kidney (except renal pelvis)
C70.0	Malignant neoplasm of meninges
C71.0	Malignant neoplasm of brain

1–10 of 12

1/2

HCPCS updatesHCPCS

C9142L	Vegzelma biosimilar reference (RT4 addition)
C9142	Removed HCPCS code
Q51261	Added HCPCS code
Q51291	Added HCPCS code

inv-21: Maximum IV dosing — <= 15 mg/kg every 3 weeks or <= 10 mg/kg every 2 weeks

Maximum IV dosing (oncology)Dose must not exceed 15 mg/kg IV every 3 weeks or 10 mg/kg IV every 2 weeks

Dose guardrail for dose increasesAny request for a dose increase must meet dose limits (<=15 mg/kg q3w or <=10 mg/kg q2w) or be supported by practice guidelines/peer‑reviewed literature

Reference for roundingSee Appendix F for dose rounding and vial quantity recommendations when calculating mg/kg doses

inv-22: Intravitreal dose — <= 2.5 mg per dose

Intravitreal per-dose capIntravitreal bevacizumab dose must not exceed 2.5 mg per dose

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required / Documentation Expectations

Prior authorization may be required for certain bevacizumab products (including some biosimilars such as Mvasi and Zirabev) depending on the requested product, indication, and line of business. Providers must submit complete clinical documentation to support that the member meets all approval criteria. Failure to provide requested documentation (office/clinic notes, relevant labs, pathology reports, current treatment regimen documentation, and any supporting peer‑reviewed literature for off‑label uses) may result in denial or delay of the request.

Prior authorization may be required for Mvasi and Zirabev for some requests
Providers must submit office chart notes, labs, and other clinical information supporting that member meets approval criteria
Incomplete documentation may result in denial or delay

Denial Risk

Off‑Label Use — Documentation and Approval Conditions

Requests for bevacizumab (Avastin) and its biosimilars for non‑FDA‑approved (off‑label) indications will not be authorized unless sufficient supporting documentation is provided per the applicable off‑label use policy for the line of business. For off‑label adult oncology indications, prescriber must document diagnosis, age, oncologist involvement (prescribed by or in consultation with an oncologist), and cite practice guidelines or peer‑reviewed literature supporting the dose and use when required.

Background

Bevacizumab and its listed biosimilars are monoclonal antibodies that act as VEGF‑specific angiogenesis inhibitors. They are used across multiple malignancies and for selected ophthalmology indications when given as the intravitreal formulation. Coverage and dosing align with FDA‑approved indications and select NCCN‑recommended regimens; intravitreal administrations require the appropriate ophthalmology formulation and prescriber, and IV dosing is governed by the policy’s mg/kg limits and regimen‑specific criteria.

Definitions

inv-44: Bevacizumab — VEGF-specific angiogenesis inhibitor; includes Avastin and listed biosimilars

Class definitionBevacizumab: a vascular endothelial growth factor (VEGF)-specific angiogenesis inhibitor (Avastin and listed biosimilars)

Includes biosimilarsPolicy references Avastin and biosimilars such as Mvasi, Zirabev, Alymsys, Avzivi, Jobevne, Vegzelma

Therapeutic class summaryMonoclonal antibody anti‑VEGF therapy used across multiple oncology and ophthalmology indications

inv-45: National Comprehensive Cancer Network (NCCN)

NCCN abbreviationNCCN = National Comprehensive Cancer Network

Role in policyPrescribed regimens must be FDA‑approved or recommended by NCCN for many oncology indications

Step Therapy and Biosimilar Preference

Step	Requirement	Notes / Exceptions
1	Member must use preferred biosimilar (Mvasi or Zirabev) prior to coverage of non-preferred bevacizumab products	Preference applies unless both Mvasi and Zirabev are contraindicated or cause clinically significant adverse effects; prior authorization may be required for Mvasi and Zirabev

Step	Requirement for Non‑ophthalmology Oncology Uses	State Exceptions
1	For non-ophthalmology oncology requests, member must use Mvasi or Zirabev unless both are contraindicated or cause clinically significant adverse effects	States listed in Appendix E may prohibit redirection/step therapy for certain metastatic cancer settings (e.g., FL, GA, IA, LA, MS, NV, OH, OK, PA, TN, TX); in those states the redirection requirement may be bypassed

Step	Redirection Requirement	Applicability / Bypass
1	Requests may be redirected to a preferred biosimilar (e.g., Mvasi, Zirabev, or other listed preferred agents) as a utilization management step prior to approving a non-preferred bevacizumab product	Redirection is applied per template updates; option to bypass redirection exists where state regulations prohibit such redirections

Step	Policy Statement	Detail Level
1	Policy includes biosimilar preferences and redirection to preferred agents (aligned to Mvasi or Zirabev)	Specific step-edit logic (e.g., electronic prior-authorization edits) is not detailed in these document chunks; refer to system templates or Appendix E for state-specific handling

Quantity Limits and Product Information

inv-61: bevacizumab (all formulations) — 15 mg/kg q3w or 10 mg/kg q2w for IV; intravitreal dose <=2.5 mg per dose

All formulations dosing summaryIV dosing: 15 mg/kg q3w or 10 mg/kg q2w; Intravitreal: ≤2.5 mg per dose

Indication applicationThese limits apply across bevacizumab products and biosimilars for the respective intravenous and intravitreal indications

Reference sectionsSee dosing and product availability sections (Dosage & Administration; Product Availability) for regimen and vial guidance

inv-62: bevacizumab products — vial quantity recommendations by weight-based dose ranges

Vial quantity recommendationsAppendix F provides vial quantity recommendations tied to weight-based dose ranges for dose rounding (e.g., 104.99 mg = 1 x 100 mg vial; 315–419.99 mg = 1 x 400 mg vial)

Use for dosing calculations

Site of Care

Billing Rule

Intravitreal formulation required for ophthalmology indications

Intravitreal formulation is required for ophthalmology indications; submit claims and requests reflecting intravitreal administration in office/ophthalmology procedure settings—IV administration for ophthalmic uses will not be approved.

Ophthalmology dosing/use must be for bevacizumab intravitreal solution.
Site-of-care should reflect ophthalmology/office procedure for intravitreal injections.

Billing Rule

IV oncology dosing implies infusion center administration

IV oncology dosing regimens imply infusion administration in infusion settings; document appropriate site-of-care for IV oncology infusions.

IV oncology administrations are typically given in infusion centers.
Ensure documentation supports infusion-site billing where applicable.

Biosimilar Policy and Preferences

Billing Rule

Require Mvasi or Zirabev use unless contraindicated; PA may apply

For many requests, the member must use Mvasi or Zirabev unless both are contraindicated; prior authorization may still be required for these biosimilars.

Preference for Mvasi or Zirabev; document contraindication or adverse effects if requesting alternatives.
PA may be required for Mvasi or Zirabev.

Billing Rule

Mvasi or Zirabev required for non‑ophthalmology oncology unless contraindicated

For non‑ophthalmology oncology requests, members must use Mvasi or Zirabev unless both are contraindicated or cause clinically significant adverse effects; document rationale if requesting other brands.

Document contraindication or adverse reaction to Mvasi/Zirabev when requesting alternate bevacizumab products.
Requests for other brands must meet the policy's routing and documentation requirements.

Billing Rule

Policy Summary

PayerHealth Net

PolicyBevacizumab (Alymsys, Avastin, Avzivi, Jobevne, Mvasi, Vegzelma, Zirabev) - Coverage Criteria

Policy CodePolicy CP PHAR.93

Change TypeIndication updates, biosimilars added, HCPCS coding changes

Effective DateDec 1, 2011

Next Review Date

Key ActionSubmit prior authorization with supporting clinical documentation and, for non-ophthalmology requests, use preferred biosimilars (Mvasi or Zirabev) unless contraindicated.

SourceLink

On This Page

For certain off-label indications (e.g., neurofibromatosis type 2 vestibular schwannomas with hearing loss), bevacizumab may be prescribed as a single agent where specified.

Pediatric off-label oncology (Section C): Diagnoses such as diffuse high-grade glioma and medulloblastoma are covered when prescribed by or in consultation with an oncologist, with pediatric age criteria applied; doses must be within FDA limits or supported by practice guidelines/peer-reviewed literature and prescriber must submit supporting evidence. Biosimilar preference rules apply similarly, with state exceptions noted.

chunk 14; chunk 13 for dosing/support

<= 15 mg/kg q3w or <= 10 mg/kg q2w

chunk 22; see Appendix F for dose rounding

Maximum 15 mg/kg q3w or 10 mg/kg q2w

Hepatocellular carcinoma (HCC): 15 mg/kg IV every 3 weeks in combination with atezolizumab (Tecentriq) 1,200 mg IV on the same day; dosing interval q3w per regimen guidance.q3w dosing

chunk 36

Clear cell renal carcinoma: 10 mg/kg IV every 2 weeks historically used with interferon alfa (per older regimens); maximum dosing guidance remains 15 mg/kg q3w or 10 mg/kg q2w.see note

chunk 36

Glioblastoma and related CNS tumors: 10 mg/kg IV every 2 weeks dosing for glioblastoma and related high-grade CNS tumors; maximum dosing guidance applies.Maximum 15 mg/kg q3w or 10 mg/kg q2w

chunk 36

Soft tissue sarcoma: 15 mg/kg IV every 3 weeks; maximum dosing guidance applies.Maximum 15 mg/kg q3w or 10 mg/kg q2w

chunk 37

Cervical cancer: 15 mg/kg IV every 3 weeks in combination with paclitaxel and either cisplatin or topotecan until progression or unacceptable toxicity; maximum dosing guidance applies.Maximum 15 mg/kg q3w or 10 mg/kg q2w

chunk 37

Ophthalmic indications (e.g., wet AMD, DME, RVO): Intravitreal dosing typically 1.25–2.5 mg every 4 weeks depending on indication; proliferative diabetic retinopathy dosing of 1.25 mg administered 5–20 days before vitrectomy; intravitreal maximum dose 2.5 mg per dose.Maximum 2.5 mg/dose

chunk 38

Malignant pleural mesothelioma: 15 mg/kg IV every 21 days with pemetrexed 500 mg/m2 IV and cisplatin 75 mg/m2 IV for up to 6 cycles, followed by maintenance bevacizumab 15 mg/kg every 21 days until progression or unacceptable toxicity.Maintenance q21d

chunk 37

inv-50: Initial Therapy

Approval durations and dosing guardrails for initial therapy

Initial therapy dosing limits: Dose must be within FDA maximum limits for the indication or supported by practice guidelines/peer-reviewed literature (prescriber must submit supporting evidence for off-label or above-limit dosing). Standard maximums: no greater than 15 mg/kg IV every 3 weeks or 10 mg/kg IV every 2 weeks for IV regimens; intravitreal maximum 2.5 mg per dose. Approval duration: Medicaid/HIM 6 months; Commercial up to 12 months or duration of request, whichever is less.<= 15 mg/kg q3w or <= 10 mg/kg q2w; intravitreal <=2.5 mg/dose

chunks 9,13,18,53

inv-51: Initial therapy dosing

Initial dosing regimens by indication

NSCLC initial: 15 mg/kg IV every 3 weeks with carboplatin and paclitaxel.see dosing

chunk 36

Metastatic CRC initial: 5 mg/kg IV every 2 weeks OR 10 mg/kg IV every 2 weeks (depending on regimen) in combination with a fluoropyrimidine-based chemotherapy regimen; maximum dose guidance applies.Maximum 15 mg/kg q3w or 10 mg/kg q2w

chunk 35

Ovarian cancer initial: 15 mg/kg IV q3w with carboplatin/paclitaxel for up to 6 cycles followed by maintenance 15 mg/kg q3w as single agent when indicated.Maximum 15 mg/kg q3w or 10 mg/kg q2w

chunk 36

inv-52: Initial therapy and approval duration

Initial authorization

Initial therapy: Initial approval durations were aligned historically; template updates generally set initial authorization to 6 months for many lines of business with commercial exceptions (see approval duration nodes). Indication-specific combination therapy requirements apply as described in per-indication criteria.6 months (template-aligned initial authorization in some line(s))

chunk 54

inv-55: Continuation therapy examples

Continuation/maintenance guidance referenced in dosing sections and historical updates

Ovarian cancer maintenance: Following combination chemotherapy with bevacizumab, continue bevacizumab 15 mg/kg every 3 weeks as single-agent maintenance when indicated by the regimen and guideline recommendations.per dosing section

chunks 36,52

inv-56: Continuation therapy

Continuation/renewal

Continuation: Initial approval durations and continuation templates have been updated across indications; continuation requests should follow the per-indication continuation criteria and duration guidance in the policy.

chunk 54

Formulation requirement

Request must be for bevacizumab intravitreal solution; IV formulations for ophthalmology will not be approved

Typical intravitreal regimensDosing regimens commonly 1.0–2.5 mg every 4 weeks depending on indication (e.g., wet AMD, DME, RVO)

inv-23: Maximum dose — no greater than 15 mg/kg IV every 3 weeks or 10 mg/kg IV every 2 weeks

Policy maximum doseNo greater than 15 mg/kg IV every 3 weeks or 10 mg/kg IV every 2 weeks

Dose increase evidence requirementAny dose above standard limits must be supported by practice guidelines or peer-reviewed literature (prescriber must submit evidence)

Continuation/renewal implicationContinued therapy or dose escalation requests must document response and adhere to the above maximums

inv-24: Dosing frequency and maximums — varies by indication (e.g., 15 mg/kg q3w, 10 mg/kg q2w, intravitreal 1-2.5 mg q4w)

Indication-specific dosing examplesNon-squamous NSCLC and many ovarian regimens: 15 mg/kg IV every 3 weeks; certain ovarian/platinum‑resistant regimens and glioblastoma: 10 mg/kg IV every 2 weeks

Ophthalmology dosingIntravitreal regimens typically 1–2.5 mg per dose every 4 weeks; proliferative diabetic retinopathy may use 1.25 mg 5–20 days pre-vitrectomy

Other oncology examplesSoft tissue sarcoma and malignant pleural mesothelioma regimens commonly 15 mg/kg q3w; HCC with atezolizumab uses 15 mg/kg q3w

inv-25: Initial approval duration — 6 months

Initial approval duration (Medicaid/HIM)6 months

Commercial typical durationCommercial: up to 12 months or duration of request, whichever is less

Continuation requirementInitial approval durations align to these timeframes; continued therapy requires documentation of benefit/response

Off‑label uses require submission of supporting evidence (guidelines or peer‑reviewed literature) when requested
Refer to off‑label use policies: CP.CPA.09 (commercial), HIM.PA.154 (HIM), CP PMN.53 (Medicaid) as applicable

Billing Rule

Coding Disclaimers — Use Up‑to‑Date Codes

Use current professional coding guidance when submitting claims. Codes referenced in the policy are informational only; incorrect or outdated coding on the claim may trigger denial or misprocessing. Providers should verify HCPCS, CPT, and other codes at time of claim submission.

Examples of codes referenced in policy: J9035, J9999 (not otherwise classified), C9257, Q5107, Q5118, Q5126, Q5129, Q51261, Q51291
Inclusion or listing of codes does not guarantee coverage — verify most up‑to‑date coding guidance

Documentation Required

Required Clinical Documentation for Initiation and Continuation

For continuation or transition requests, documentation should show the member is currently receiving one of the listed bevacizumab products (Alymsys, Avastin, Avzivi, Jobevne, Mvasi, Vegzelma, or Zirabev) for a covered oncology indication and has received the medication for at least 30 days when applicable. For dose increases or changes, submit rationale and supporting guidelines or literature; new doses should not exceed policy dose limits unless supported by evidence.

Documentation must show current therapy for at least 30 days when required
Dose increase requests must include evidence or guideline support
Dose limits (oncology IV): ≤15 mg/kg IV q3 weeks or ≤10 mg/kg IV q2 weeks unless supported by guidelines

Note

Supporting References

Policy includes references and prescribing information for Avastin and biosimilars and relevant guideline sources. Providers may be asked to reference or supply excerpts from these documents when supporting non‑standard or off‑label uses.

Prescribing information and NCCN guideline citations may be requested to substantiate use
References listed in policy (see policy references section) were reviewed and updated periodically

Step Therapy

Biosimilar Preference, Step Therapy, and Redirection Rules

Biosimilar redirection and step preferences apply: for many oncology and other non‑ophthalmology uses, the member must use the preferred biosimilars (Mvasi or Zirabev) unless both are contraindicated or clinically significant adverse effects have been experienced. Some states have regulations that prohibit step therapy/redirection in specified oncology settings; when state regulation applies, redirection may be bypassed. Requests associated with states listed in Appendix E should follow the state‑specific exceptions.

Preferred biosimilars for redirection: Mvasi or Zirabev
Redirection may be bypassed when both preferred biosimilars are contraindicated or cause clinically significant adverse effects
State exceptions (Appendix E) — some states prohibit step therapy/redirection in advanced/metastatic cancer (e.g., FL, GA, IA, LA, MS, NV, OH, OK, PA, TN, TX) — follow Appendix E for details

Documentation Required

Biosimilar Redirection — Operational Details and Exceptions

Redirection to preferred biosimilars (e.g., Mvasi or Zirabev) is applied in the policy template; providers should include documentation if requesting a non‑preferred agent or seeking to bypass redirection due to contraindication, adverse effect, or applicable state regulation. Ophthalmology intravitreal requests are handled separately; IV formulations for ophthalmology uses will not be approved.

Include clinical rationale when requesting a non‑preferred agent or requesting bypass of redirection
Requests for IV formulations for ophthalmologic indications will be denied — intravitreal formulation and ophthalmologist prescriber required
Prior authorization may still be required for Mvasi and Zirabev depending on line of business

Reference usagePolicy updates and indication qualifiers reference NCCN recommendations

inv-46: colorectal cancer (CRC) abbreviation

AbbreviationCRC = colorectal cancer

Policy qualifierFor CRC, disease must be advanced/metastatic/unresectable and used in combination with an appropriate chemotherapy regimen

Dosing exampleMetastatic CRC dosing includes 5 or 10 mg/kg IV regimens with maximums 15 mg/kg q3w or 10 mg/kg q2w

inv-47: Redirection — policy language directing use of preferred biosimilars

Redirection definitionPolicy language directs use of preferred biosimilars (e.g., Mvasi, Zirabev) in place of Avastin where applicable

Template updatesRedirection and 'must use' language applied via template updates and may be bypassed where state regulations prohibit redirection (see Appendix E)

Practical effectProviders may be required to use preferred biosimilar or justify contraindication to access other brands

inv-48: Ophthalmology prescriber requirement — ophthalmology uses require an ophthalmologist prescriber

Prescriber requirementOphthalmology uses require that the medication be prescribed by or in consultation with an ophthalmologist

Scope expansionOphthalmology coverage expanded to include choroidal neovascularization from any cause, radiation retinopathy, and retinopathy of prematurity

Formulation restrictionIntravitreal formulation required; IV formulations for ophthalmology will not be approved

Follow Appendix F when converting mg/kg doses to vial counts for dispensing and quantity limits

Applies to all brandsVial rounding recommendations apply to Avastin and listed biosimilars per the Appendix

inv-63: bevacizumab — single-use vials: 100 mg/4 mL, 400 mg/16 mL

Single-use vial sizesBevacizumab single-use vials: 100 mg/4 mL and 400 mg/16 mL

Preparation noteVial sizes correspond to Appendix F dose rounding recommendations for weight-based dosing

Product availability sectionSee Product Availability for listed vial presentations used across brands and biosimilars

inv-64: bevacizumab and biosimilars — related quantity limit info

Quantity limit linkageQuantity limits and dose rounding guidance are provided for bevacizumab and biosimilars, with Appendix F detailing vial recommendations

Redirection and coding impactPolicy updates include redirection to preferred biosimilars which may affect which product/vial is authorized; HCPCS updates listed in policy may affect billing

Documentation and PA impactPrior authorization and supporting documentation requirements apply equally to Avastin and listed biosimilars when quantity limits and dosing are evaluated

Billing Rule

Match administration route to appropriate site-of-care

IV oncology dosing should be administered in infusion settings; intravitreal dosing must be administered in ophthalmology/office procedure settings as appropriate for the route.

Match administration route to site-of-care: IV → infusion center; intravitreal → ophthalmology office/procedure.
Document site and route in PA and claim submissions.

Documentation Required

Ophthalmologist prescriber required for ophthalmology uses

Ophthalmology administrations require an ophthalmologist prescriber; ensure prescriber specialty is documented with the request for intravitreal uses.

Ophthalmologist must prescribe or be in consultation for ophthalmology indications.
Include prescriber specialty in submitted documentation.

Policy redirects to preferred biosimilars; document exceptions

The policy applies redirection to preferred biosimilars (Mvasi, Zirabev, Vegzelma, Avzivi, Alymsys, Jobevne) per template updates; providers must follow redirection unless a state regulation or documented contraindication permits bypass.

Redirection templates prioritize preferred biosimilars; document exception rationale if not following redirection.
State-specific Appendix E entries may allow bypass of redirection.

Billing Rule

Redirection preference aligned to Mvasi or Zirabev

Redirection preferences align primarily to Mvasi or Zirabev for certain utilization management pathways; include documentation if requesting a non‑preferred biosimilar or reference product.

Primary redirection preference: Mvasi or Zirabev.
Document clinical justification when requesting other bevacizumab products.