CurrentHighmark DelawarePolicy N/A

Outpatient Avastin (Bevacizumab) chemotherapy request form

This document is a faxable outpatient chemotherapy request form for bevacizumab and its biosimilars under the medical benefit, to be completed by the requesting physician or facility and used for prior authorization determination.

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Avastin (Bevacizumab) chemotherapy request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed form and supporting clinical documentation to 833-619-5745 to request prior authorization for outpatient bevacizumab or biosimilars.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2preferred product options listed

3non-preferred product options listed

833-619-5745fax number for submission

J9035example HCPCS/J-codes shown on form

Coverage Criteria

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.

Authorization criteria

Coverage consideration requires completion of the form and supporting clinical documentation demonstrating medical necessity.

Form completion and patient data: Member identifiers, payer (Medicare or Commercial), requesting physician and facility details, date of service, and J‑code(s)/diagnosis code(s) must be provided on the form

See form fields including Member Name, DOB, UMI, payer checkbox, physician and facility sections

Clinical details: Provide cancer type and histology, disease stage, complete chemotherapy regimen, line of therapy, prior therapies with response (progression/relapse), ECOG performance status, and resectability status

Attach pertinent clinical information (progress notes, genetic testing) as indicated on the form

Preferred product trial: If a non‑preferred product is requested, documentation of failure, intolerance, or contraindication to a preferred product is required (except Medicare members already established on non‑preferred therapy)

Provide rationale in the form field when non‑preferred selected

Use of a non-preferred product without documentation of prior failure, intolerance, or contraindication to a preferred bevacizumab product may be excluded from coverage. The request form must be completed with required patient identifiers, payer type, J-code(s), diagnosis code(s), and clinical details (cancer type/histology, stage, complete regimen, line of therapy, prior therapies and response, ECOG performance status, and resectability) to support medical necessity and consideration of a non-preferred agent.

Selection of a non-preferred bevacizumab product (for example, Avastin/J9035 or other non-preferred options listed on the form) without providing the required justification on the form may be considered not medically necessary by the plan. When a non-preferred product is requested, the form requires a rationale explaining why a preferred biosimilar was not used; Medicare members already established on a non-preferred therapy are exempt from the preferred-product trial requirement.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Submission

Prior authorization is required for outpatient bevacizumab (Avastin) and biosimilar requests. Submit the completed Outpatient Chemotherapy Avastin (Bevacizumab) Request Form with all clinical questions answered and supporting documentation via fax to 833-619-5745.

Fax: 833-619-5745
Use the completed Outpatient Chemotherapy Avastin (Bevacizumab) Request Form
Applies to medical benefit (J-code) claims

Denial Risk

Non‑Preferred Product Justification

A non-preferred product (for example, Avastin biosimilars listed as non-preferred) will be considered only when the member has documented failure of an adequate therapeutic trial of a preferred product, or when the preferred product is not tolerated or is contraindicated. Medicare members already established on a non-preferred therapy are not required to trial a preferred option.

Non-preferred examples: Avastin (J9035), Alymsys, Vegzelma
Medicare established members exempt from preferred-product trial requirement

Documentation Required

Required Documentation

The request form must include member identifiers and payer type (Medicare or Commercial); requesting physician and facility details (including NPI and addresses); date of service; J‑code(s) and diagnosis code(s); and answers to all clinical questions. Attach all pertinent clinical information (progress notes, regimen details, prior therapies, ECOG score, resectability status, genetic testing, etc.).

Member name, DOB, UMI
Payer type: Medicare or Commercial
Requesting physician name, NPI, address, office contact, phone, fax
Facility name, NPI, address
Date of service, J‑code(s), diagnosis code(s)
Clinical questions: cancer type/histology/stage, complete chemotherapy regimen, line of therapy, prior therapies and response, ECOG score, resectability
Attach supporting documentation (progress notes, testing) — indicate Attached: YES/NO

Denial Risk

Non‑Preferred Product — Risk of Non‑Coverage

Selection of a non-preferred product without documentation of prior failure, intolerance, or contraindication to a preferred product may result in non-coverage. If a non-preferred product is selected, provide the rationale on the form.

Provide rationale on form when requesting a non-preferred product
Lack of documented rationale may lead to denial or non-coverage

Definitions

Preferred — Preferred products

Preferred productsMvasi (Q5107) and Zirabev (Q5118) are listed as preferred for all indications

Non-preferred examplesAvastin (J9035), Alymsys, Vegzelma are listed as non-preferred options on the form

Non-preferred exceptionMedicare members currently established on a non-preferred therapy are not required to try a preferred option

Requirement for non-preferred coverageA non-preferred product will be considered only when there is documented therapy failure after an adequate trial of a preferred product, or the preferred product is not tolerated or is contraindicated

Non-preferred — Non-preferred products

Non-preferred productsAvastin (J9035), Alymsys (blank field on form), Vegzelma (blank field on form)

Justification requiredIf a non-preferred product is selected, the form requires a rationale explaining selection over a preferred product

Coverage conditionNon-preferred product considered only after documented failure of a preferred product, intolerance, or contraindication

Medicare exemptionMedicare members currently established on a non-preferred therapy are exempt from the preferred-product trial requirement

Initial Therapy Criteria

Non-preferred product criteria

Non‑preferred bevacizumab products will be considered only under specific conditions.

When non‑preferred allowed: Member has documented therapy failure after an adequate therapeutic trial of a preferred product OR preferred product not tolerated OR preferred product is contraindicated

Medicare members currently established on a non‑preferred therapy are exempt from the trial requirement; when non‑preferred selected provide rationale on the form

Step	Requirement	Medicare exception
1	Documentation of therapy failure after an adequate therapeutic trial of a preferred product, OR documentation that a preferred product is not tolerated or is contraindicated	Medicare members currently established on a non-preferred therapy are exempt from the preferred-product trial requirement

Biosimilar Preferences

Billing Rule

Preferred biosimilars (Mvasi, Zirabev)

Mvasi (Q5107) and Zirabev (Q5118) are listed as preferred products for all indications on the form.

Select preferred biosimilar option(s) on the form where applicable.

Billing Rule

Avastin (J9035) designated non-preferred — requires justification

Avastin (J9035) is listed as a non-preferred product on the form and requires documentation per the non-preferred product policy when requested.

If selecting Avastin (J9035), provide documented failure/intolerance/contraindication to preferred products or rationale for selection; Medicare-established members are exempt from trial requirement.

Background

Bevacizumab and its biosimilars are used as outpatient chemotherapy agents across multiple cancer indications. The outpatient chemotherapy request form collects tumor details (type, histology, stage), full chemotherapy regimen and line of therapy, prior treatments and whether the member progressed or relapsed, ECOG performance status, and resectability status, and it requests attachment of pertinent clinical documents (progress notes, genetic testing) to document medical necessity for bevacizumab or a biosimilar.

OpenPayer