CurrentViva HealthPolicy IC-0295

Bavencio (avelumab) (Intravenous)

Clinical coverage and prior authorization criteria for use of avelumab (Bavencio) for multiple oncologic indications for Viva Health members, including initial and renewal authorization, dosing, and indication-specific requirements.

Policy Summary

PayerViva Health

PolicyBavencio (avelumab) (Intravenous) - coverage criteria

Policy CodePolicy IC-0295

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateApr 1, 2026

Key ActionObtain prior authorization: initial approval provided for 180 days and may be renewed every 180 days based on documented clinical benefit and tolerability.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

800 mg q14dstandard dosing (max units per 14 days)

6 moinitial prior authorization length

6 morenewal interval

600 mg ≤66 kgweight-based alternative

Multiplecovered ICD-10 codes

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Universal Criteria

Covered when ALL of the following universal criteria are met

Universal: Member is at least 18 years of age unless otherwise indicated; member has not received previous PD-1/PD-L1-directed therapy unless otherwise specified; dosing and authorization requirements are met (see coverage conditions and prior authorization guidance).

Merkel Cell Carcinoma (MCC)

Covered for Merkel Cell Carcinoma when ALL of the following are met

MCC_general: Member is at least 12 years of age; used as single-agent therapy; and disease is one of: primary locally advanced disease where both curative surgery and curative radiation are not feasible; recurrent locally advanced disease where both curative surgery and curative radiation are not feasible or disease progressed on neoadjuvant nivolumab; in-transit node-positive regional disease; metastatic disease; or primary/recurrent regional disease where both curative surgery and curative radiation are not feasible.

Urothelial Carcinoma (Bladder Cancer)

Covered for Urothelial Carcinoma when ONE of the following scenarios applies

Urothelial_scenarios: Scenario A: Used as single-agent therapy for locally advanced or metastatic urothelial carcinoma that progressed during or following platinum-containing chemotherapy. OR Scenario B: Used as first-line maintenance treatment for locally advanced or metastatic urothelial carcinoma (including bladder, upper GU tract, urethra, and/or prostate) when the member has not progressed on first-line platinum-containing chemotherapy.

Renal Cell Carcinoma (RCC)