Viva Health bevacizumab Coverage & Prior Auth

Coverage Criteria and Indication-Specific Rules

inv-01: Universal Initial Criteria

Initial approval requires ALL of the following universal criteria:

Universal: Patient must have a contraindication, intolerance, or failure to Alymsys AND Mvasi prior to consideration of another bevacizumab product; patient is at least 18 years of age unless otherwise specified; no recent history of hemoptysis (≥2.5 mL blood in sputum); and no surgical procedure within the preceding 28 days and no unhealed surgical wound.

inv-02: Ampullary Adenocarcinoma

Ampullary Adenocarcinoma — Covered when ALL of the following are met:

Ampullary Adenocarcinoma: Used in combination with a fluoropyrimidine-based regimen (e.g., 5-FU or capecitabine) for intestinal-type disease; and either used as first-line therapy for metastatic disease or used for disease progression.

inv-03: Adult CNS Cancers (symptom management and other CNS uses)

Adult CNS Cancers — Covered when ANY of the following indication-specific conditions are met in addition to universal criteria:

CNS symptomatic indications: Used as single-agent for symptomatic mass effect, radiation necrosis, or brain edema in patients with listed CNS tumor types (examples: circumscribed glioma, primary CNS lymphoma, meningiomas, brain or spine metastases, primary spinal cord tumors, medulloblastoma, glioblastoma/gliosarcoma, H3‑mutated high‑grade glioma/HGAP/PXA WHO grade 3, IDH‑mutant astrocytoma WHO grade 2–4, IDH‑mutant 1p19q‑codeleted oligodendroglioma WHO grade 2–3, intracranial or spinal ependymoma excluding subependymoma).

CNS recurrent/progressive: Used for recurrent or progressive disease for specified tumor types (e.g., IDH‑mutant 1p19q‑codeleted oligodendroglioma WHO grade 3; glioblastoma/gliosarcoma; H3‑mutated high‑grade glioma/HGAP/PXA WHO grade 3; IDH‑mutant astrocytoma WHO grade 3–4) as single agent or in combination with carmustine, lomustine, or temozolomide; and may be considered when patient has failed prior bevacizumab monotherapy where specified.

Other CNS uses: Used as single agent for intracranial or spinal ependymoma after prior radiation; used in combination with temozolomide and irinotecan for recurrent medulloblastoma; used as single agent for surgically inaccessible meningiomas when radiation is not possible; and used as single agent for NF2 vestibular schwannomas with hearing loss.

inv-04: Cervical Cancer

Cervical Cancer — Covered when ALL of the following are met:

Cervical Cancer: Patient has persistent, recurrent, or metastatic disease of adenocarcinoma, adenosquamous, or squamous histology; used in combination with paclitaxel and either cisplatin, carboplatin, or topotecan; or used in combination with pembrolizumab plus paclitaxel and either cisplatin or carboplatin when tumor PDL1 (CPS) ≥1 by an FDA‑approved or CLIA‑compliant test; or used in combination with atezolizumab plus paclitaxel and either cisplatin or carboplatin; or used as single‑agent subsequent therapy. Small cell neuroendocrine carcinoma (NECC) regimens specified (paclitaxel + topotecan) apply for first‑line or subsequent therapy. Bevacizumab and certain immunotherapy regimens may be continued as maintenance as noted.PDL1 (CPS) >=1

PDL1 testing must be FDA‑approved or CLIA‑compliant.

inv-05: Colorectal Cancer

Colorectal Cancer (CRC) — Covered when ALL of the following are met:

CRC: Will not be used as part of adjuvant treatment; used in combination with a fluoropyrimidine‑based regimen as first‑line or subsequent therapy for metastatic, unresectable, or advanced disease; or used in combination with irinotecan as initial treatment for unresectable metastatic disease (with prior FOLFOX/CapeOX within 12 months where specified); or used in combination with irinotecan‑based therapy or with trifluridine/tipiracil as subsequent therapy after progression through available regimens; or used as primary treatment for specified rectal staging when resection is contraindicated following neoadjuvant/definitive therapy.

Refer to NCCN guidelines; universal MMR/MSI testing recommended and dMMR/MSI‑H or ultrahypermutated (TMB>50) tumors should be treated with checkpoint inhibitors when appropriate.

inv-06: Appendiceal Neoplasms and Cancers

Appendiceal Neoplasms and Cancers — Covered when ALL of the following are met:

Appendiceal: Used as neoadjuvant therapy or for biopsy‑proven recurrence of high‑risk disease in combination with a fluoropyrimidine‑based regimen; used for metastatic peritoneal‑only disease or as initial therapy for recurrent/metastatic peritoneal‑only or extraperitoneal disease in combination with a fluoropyrimidine‑based regimen; or used as subsequent therapy in combination with a fluoropyrimidine‑ or irinotecan‑based regimen or with trifluridine/tipiracil after progression through available regimens.

Refer to NCCN guidance.

inv-07: Endometrial Carcinoma

Endometrial Carcinoma — Covered when ALL of the following are met:

Endometrial: Used for recurrent disease; will not be used for locoregional recurrence in patients without prior radiation to the site of recurrence or after surgical exploration confined to vagina/paravaginal soft tissue; and may be used as single‑agent subsequent therapy after progression on cytotoxic chemotherapy, or in combination with carboplatin and paclitaxel and continued as single‑agent maintenance, or as primary/adjuvant therapy for stage III–IV disease in combination with carboplatin and paclitaxel with continued single‑agent maintenance.

inv-08: Hepatocellular Carcinoma

Hepatocellular Carcinoma (HCC) — Covered when ALL of the following are met:

HCC: Used in combination with atezolizumab as first‑line therapy for unresectable or metastatic disease, or used as subsequent therapy for progression on or after systemic therapy; and patient has not received prior treatment with bevacizumab or a checkpoint inhibitor.

inv-09: Peritoneal Mesothelioma

Peritoneal Mesothelioma — Covered when ALL of the following are met:

Peritoneal Mesothelioma: Used as adjuvant therapy following CRS+HIPEC in combination with pemetrexed and either cisplatin or carboplatin for patients with surgical/pathologic high‑risk features; or used as first‑line or subsequent therapy in combination with pemetrexed and platinum under specified conditions (e.g., medically inoperable disease, inability to achieve complete cytoreduction, presence of high‑risk features, progression after CRS+HIPEC); may be used with atezolizumab if no prior checkpoint inhibitor therapy.

High‑risk features include Ki‑67 >9%, nodal metastasis, thrombocytosis, PS=2, PCI>17, cc>1, biphasic/sarcomatoid histology, or bicavitary disease.

inv-10: Pleural Mesothelioma

Pleural Mesothelioma — Covered when ALL of the following are met:

Pleural Mesothelioma: Used in combination with pemetrexed and either cisplatin or carboplatin as induction prior to surgical exploration for clinical stage I epithelioid histology, or used as first‑line or subsequent therapy; may be rechallenged after prior pemetrexed‑based first‑line response.

inv-11: Non-Squamous Non-Small Cell Lung Cancer (NSCLC)

Non‑Squamous Non‑Small Cell Lung Cancer (NSCLC) — Covered when specified biomarker and combination therapy conditions are met:

NSCLC first‑line: Used for recurrent, advanced, or metastatic disease as first‑line therapy in combination regimens depending on biomarker status (examples: with erlotinib for EGFR exon 19 deletion or L858R; with carboplatin and paclitaxel; or with atezolizumab, carboplatin, and paclitaxel). Actionable biomarker testing (EGFR, KRAS, ALK, ROS1, BRAF, NTRK, MET, RET, NRG1, ERBB2) is recommended to guide selection.

NSCLC subsequent/maintenance: Used as subsequent therapy in combination with atezolizumab, carboplatin, and paclitaxel (excluding patients with prior PD‑1/PD‑L1 inhibitor therapy); or used as continuation maintenance after response or as single‑agent maintenance if bevacizumab was included in first‑line; includes biomarker‑dependent pathways and contraindication notes for PD‑1/PD‑L1 inhibitors.

PD‑1/PD‑L1 contraindications may include active autoimmune disease or immunosuppression.

inv-12: Ovarian, Fallopian Tube, and Primary Peritoneal Cancer

Ovarian, Fallopian Tube, and Primary Peritoneal Cancer — Covered when specified histology, platinum‑sensitivity, biomarker, and combination regimen criteria are met:

Ovarian general: Coverage varies by histology and platinum sensitivity: uses include single‑agent for relapsed sex cord‑stromal tumors; combinations for platinum‑resistant or platinum‑sensitive disease; maintenance uses and combinations with PARP inhibitors contingent on BRCA1/2 and homologous recombination (HR) status and histology; neoadjuvant, adjuvant, post‑IDS, and continued treatment contexts specified with surgical candidacy criteria.

BRCA1/2 and HR status considerations apply; refer to histology‑specific subclauses.

Gynecologic combinations and maintenance: Used in combination with paclitaxel and carboplatin for rising CA‑125 or clinical relapse in patients with no prior chemotherapy for specified histologies; used as maintenance therapy following primary therapy including bevacizumab; used as single agent in BRCA1/2 wild‑type or unknown patients with certain histologies; used in combination with olaparib or niraparib as indicated.

Surgical timing and histology clauses: Neoadjuvant and IDS settings: used following IDS for response or stable disease to neoadjuvant therapy (endometrioid and serous only) when patient is poor surgical candidate or unlikely to achieve optimal cytoreduction; adjuvant use with oxaliplatin/docetaxel excludes grade 1 endometrioid and low‑grade serous carcinoma; detailed histology limits and BRCA/HR requirements apply per subclauses.

inv-13: Ovarian/Fallopian Tube/Primary Peritoneal Cancer

Ovarian/Fallopian Tube/Primary Peritoneal Cancer — covered when specific histology, setting, and biomarker criteria are met:

Overall allowed contexts: Used in combination with paclitaxel and carboplatin for rising CA‑125 or clinical relapse or recurrence in patients with no prior chemotherapy for specified histologies; used as maintenance therapy; used as single agent following recurrence therapy with chemotherapy plus bevacizumab for platinum‑sensitive disease; continued treatment following neoadjuvant therapy for endometrioid and serous histology; neoadjuvant, adjuvant, and post‑IDS uses with histology and surgical candidacy criteria specified.

See histology and biomarker subclauses.

Histology/biomarker clauses: Coverage specifies histology‑limited uses (grade 2/3 endometrioid, high‑grade serous, mucinous, clear cell, carcinosarcoma, low‑grade serous in limited contexts) and requires BRCA1/2 wild‑type or unknown with HR deficiency or germline/somatic BRCA1/2 mutation for certain single‑agent or combination uses.

Surgical timing and candidacy: Neoadjuvant and interval debulking surgery settings: used following IDS for response or stable disease to neoadjuvant therapy (endometrioid and serous only) when patient is a poor surgical candidate or unlikely to achieve optimal cytoreduction; adjuvant use in pathologic stage II–IV excludes grade 1 endometrioid and low‑grade serous carcinomas for certain regimens.

inv-14: Pediatric Central Nervous System (CNS) Cancers

Pediatric CNS Cancers — covered for specific tumor types, ages, and regimens:

Pediatric CNS uses: Recurrent or progressive diffuse high‑grade glioma (≤21 years) as single‑agent palliative; medulloblastoma (age 3–21) as part of TEMR or MEMMAT regimens; optic pathway glioma (<18 years) as subsequent treatment to preserve vision (single agent or with standard therapies); NF2 vestibular schwannomas (≥6 years) with hearing loss in at least one ear; continuation after progression on bevacizumab to preserve vision/hearing as specified.

Age and histology restrictions apply.

inv-15: Renal Cell Carcinoma (RCC)

Renal Cell Carcinoma (RCC) — Covered when indication‑specific criteria are met:

RCC contexts: Used in combination with interferon alfa for metastatic disease; or in relapsed or stage IV non‑clear cell histology in combination with everolimus or with erlotinib for advanced papillary disease including HLRCC‑associated RCC. When used first‑line for stage IV disease, disease must be M1 or unresectable T4, M0.

inv-16: Respiratory Papillomatosis

Respiratory Papillomatosis — Covered when indication‑specific criteria are met:

Adjunct use: Used as an adjunct to endobronchial therapy (e.g., surgical excision, debridement) for recurrent disease.

inv-17: Small Bowel Adenocarcinoma

Small Bowel Adenocarcinoma — Covered when ALL of the following are met:

Small Bowel Adenocarcinoma: Patient has advanced or metastatic disease and bevacizumab is used in combination with a fluoropyrimidine‑based regimen; used as initial therapy if pMMR/MSS disease or as subsequent therapy if not previously given.

inv-18: Soft Tissue Sarcoma (STS)

Soft Tissue Sarcoma (STS) — Covered when ALL of the following are met:

STS uses: Used as a single agent for angiosarcoma; or used in combination with temozolomide for solitary fibrous tumor.

inv-19: Vaginal Cancer

Vaginal Cancer — Covered when ALL of the following are met:

Vaginal cancer contexts: Patient has recurrent or metastatic disease and bevacizumab is used in combination with paclitaxel and either cisplatin, carboplatin, or topotecan as first‑line or subsequent therapy; or used in combination with pembrolizumab, paclitaxel, and either cisplatin or carboplatin when tumor PDL1 (CPS) ≥1 by an FDA‑approved or CLIA‑compliant test for first‑line or subsequent therapy; or used as single‑agent subsequent therapy.PDL1 (CPS) >=1

PDL1 testing must be FDA‑approved or CLIA‑compliant.

inv-20: Vulvar Cancer

Vulvar Cancer — Covered when ALL of the following are met:

Vulvar cancer contexts: Patient has advanced, recurrent, or metastatic disease; used as first‑line or subsequent therapy (if not previously used) in combination with paclitaxel and either cisplatin or carboplatin, or in combination with pembrolizumab plus paclitaxel and cisplatin/carboplatin; bevacizumab (and pembrolizumab where used) may be continued as maintenance as noted.

Will not be used as part of adjuvant treatment for colorectal cancer. For metastatic, unresectable, or advanced colorectal disease, bevacizumab is covered only in combination with a fluoropyrimidine-based regimen or with irinotecan-based therapy as specified in the colorectal coverage criteria and per NCCN guidance; adjuvant (post‑resection) use is excluded.

Will not be used for locoregional recurrence in endometrial carcinoma without prior radiation to the site of recurrence or after surgical exploration confined to the vagina or paravaginal soft tissue. Coverage for endometrial carcinoma is limited to recurrent disease and to the specific combination or single‑agent contexts described in the policy (for example, combination with carboplatin/paclitaxel with continuation as single‑agent maintenance, or single‑agent subsequent therapy after progression on cytotoxic chemotherapy).

Certain regimens explicitly exclude use in grade 1 endometrioid carcinoma and low grade serous carcinoma. Specifically, oxaliplatin/docetaxel combinations and adjuvant oxaliplatin/docetaxel are not allowed for these lower‑grade histologies as noted in the ovarian/fallopian tube/primary peritoneal cancer criteria and associated surgical/adjuvant clauses.

Indication	Covered bevacizumab combination/regimen	Coverage status
Colorectal cancer (CRC)
Bevacizumab in combination with fluoropyrimidine-based regimens (e.g., FOLFOX, CapeOX, FOLFIRI) for metastatic/unresectable CRC; may be continued after progression per clinical context

Indication	Covered bevacizumab combination/regimen	Coverage status
Ovarian, fallopian tube, primary peritoneal cancer (gynecologic cancers)
Bevacizumab combined with paclitaxel + carboplatin; carboplatin + paclitaxel or docetaxel; oxaliplatin + docetaxel (with histology exclusions); used as maintenance or single agent in biomarker-specified contexts; may be combined with PARP inhibitors (olaparib or niraparib) when specified by BRCA/HR status

Indication	Covered bevacizumab combination/regimen	Coverage status
Pediatric central nervous system (CNS) tumors
Single-agent bevacizumab or in combination as part of TEMR (temozolomide, irinotecan, bevacizumab) or MEMMAT (thalidomide, celecoxib, fenofibrate, etoposide, cyclophosphamide, bevacizumab) regimens; also combined with standard therapies (e.g., irinotecan, carboplatin, vinblastine) depending on tumor type and age-specific criteria

Indication	Covered bevacizumab combination/regimen	Coverage status
Small bowel adenocarcinoma
Bevacizumab combined with a fluoropyrimidine-based regimen (e.g., 5-FU or capecitabine) for advanced/metastatic disease; used as initial therapy if tumor is pMMR/MSS or as subsequent therapy if not previously given

Reference	Regimen / finding cited	Notes
Hurwitz H et al. (Bevacizumab + irinotecan/5-FU/leucovorin)
Supports bevacizumab combined with irinotecan and fluorouracil/leucovorin in metastatic colorectal cancer (clinical trial evidence)

Billing, Code Lists, and Unit Limits

HCPCS unitsmixed

HCPCS units

Max billable units specified per indication groups (see policy)

HCPCS CodesHCPCS

J9035	Injection, bevacizumab, 10 mg; 1 billable unit = 10 mg
Q5107	Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg; 1 billable unit = 10 mg
Q5118	Injection, bevacizumab-bvzr, biosimilar, (zirabev), 10 mg; 1 billable unit = 10 mg
Q5126	Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg; 1 billable unit = 10 mg
Q5129	Injection, bevacizumab-adcd, (vegzelma), biosimilar, 10 mg; 1 billable unit = 10 mg
Q5160	Injection, bevacizumab-nwgd (jobevne), biosimilar, 10 mg; 1 billable unit = 10 mg (Effective 01/01/2026)
J9999	Not otherwise classified, antineoplastic drugs (Avzivi and Jobevne only) (Discontinue use on 01/01/2026 for Jobevne only)

NDCsNDC

50242-0060-xx	Avastin single-dose vial, 100 mg/4 mL solution for injection
50242-0061-xx	Avastin single-dose vial, 400 mg/16 mL solution for injection
55513-0206-xx	Mvasi single-dose vial, 100 mg/4 mL solution for injection
55513-0207-xx	Mvasi single-dose vial, 400 mg/16 mL solution for injection
00069-0315-xx	Zirabev single-dose vial, 100 mg/4 mL solution for injection
00069-0342-xx	Zirabev single-dose vial, 400 mg/16 mL solution for injection
70121-1754-xx	Alymsys single-dose vial, 100 mg/4 mL solution for injection
70121-1755-xx	Alymsys single-dose vial, 400 mg/16 mL solution for injection
72606-0011-xx	Vegzelma single-dose vial, 100 mg/4 mL solution for injection
72606-0012-xx	Vegzelma single-dose vial, 400 mg/16 mL solution for injection

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Covered ICD-10 Diagnosis CodesICD-10Covered

C17.0	Malignant neoplasm duodenum
C17.1	Malignant neoplasm jejunum
C17.2	Malignant neoplasm ileum
C17.3	Meckel's diverticulum, malignant
C17.8	Malignant neoplasm of overlapping sites of small intestines
C17.9	Malignant neoplasm of small intestine, unspecified
C18.0	Malignant neoplasm of cecum
C18.1	Malignant neoplasm of appendix
C18.2	Malignant neoplasm of ascending colon
C18.3	Malignant neoplasm of hepatic flexure

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Covered ICD-10 Diagnosis Codes (Appendix 1)ICD-10Covered

C45.9	Mesothelioma, unspecified
C48.0	Malignant neoplasm of retroperitoneum
C48.1	Malignant neoplasm of specified parts of peritoneum
C48.2	Malignant neoplasm of peritoneum, unspecified
C48.8	Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum
C49.0	Malignant neoplasm of connective and soft tissue of head, face and neck
C49.10	Malignant neoplasm of connective and soft tissue of unspecified upper limb, including shoulder
C49.11	Malignant neoplasm of connective and soft tissue of right upper limb including shoulder
C49.12	Malignant neoplasm of connective and soft tissue of left upper limb, including shoulder
C49.20	Malignant neoplasm of connective and soft tissue of unspecified lower limb, including hip

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Max billable units per indication group

Appendiceal / Small bowel / Ampullary180 HCPCS units per 42 days

NSCLC / Cervical / HCC / Vaginal / Vulvar / Endometrial / Mesotheliomas170 HCPCS units per 21 days

CRC / CNS / RCC / Respiratory Papillomatosis / All other indications360 HCPCS units per 42 days

Dose ranges

Lower-range dosing5 mg/kg IV every 2 weeks (also used as 7.5 mg/kg IV every 3 weeks for some indications)

Typical maintenance/standard dosing

Authorization, Documentation, and Denial Risk Guidance

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Prior authorization is required and initial authorizations are generally valid for 6 months (except adult CNS symptom management which is valid for 12 weeks). Renewals may be requested every 6 months unless otherwise specified.

Initial validity: 6 months (12 weeks for adult CNS symptom management).
Renewal frequency: may be renewed every 6 months unless noted otherwise.
Biosimilar step requirement: patient must have a contraindication, intolerance, or failure to Alymsys® AND Mvasi® prior to consideration of another bevacizumab product.

Documentation Required

Renewal Authorization Requirements

Renewal authorizations require documentation that the member continues to meet both the universal criteria and the indication‑specific criteria (including any concomitant therapy requirements where applicable). Renewals will not be issued if the original duration limit has been exceeded.

Line of Therapy and Sequencing Rules

inv-51: mixed

Mixed line‑of‑therapy rules across indications:

Line examples: Indications specify first‑line, subsequent, maintenance, neoadjuvant, adjuvant, or rechallenge contexts depending on tumor type (examples include first‑line with atezolizumab for HCC; first‑line or subsequent in CRC; first‑line or subsequent in mesothelioma per criteria).

inv-52: first-line | subsequent

First‑line and subsequent therapy logic for various indications:

Line of therapy examples: Bevacizumab is specified as first‑line or subsequent therapy depending on indication (e.g., first‑line or subsequent in vulvar/vaginal cancers; first‑line in combination regimens for certain ovarian settings; continuation after progression in some contexts).

Biomarker and Molecular Testing Requirements

PD-L1 (CPS)

PD-L1 (CPS) requirementPD-L1 Combined Positive Score (CPS) ≥1 required when specified (e.g., cervical, vaginal cancer regimens with pembrolizumab)

Test standardPD-L1 CPS must be determined by an FDA-approved or CLIA-compliant test

Applies toCervical cancer and selected vaginal indications when used with pembrolizumab-containing regimens

MMR / MSI (and TMB / POLE / POLD1)

MMR / MSI requirementUniversal MMR/MSI testing recommended for CRC; use checkpoint inhibitors for dMMR/MSI-H or ultrahypermutated tumors

TMB / POLE / POLD1Ultrahypermutated phenotype (e.g., TMB > 50 mut/Mb or POLE/POLD1 mutation) may indicate checkpoint inhibitor therapy

Examples of Covered Combination Regimens

Example context (tumor type)	Example bevacizumab combination/regimen	Coverage status
Colorectal cancer / Appendiceal neoplasms
Bevacizumab with fluoropyrimidine-based regimens (FOLFOX, CapeOX, FOLFIRI); continuation after progression described in trial data

Gynecologic context	Bevacizumab combination/regimen	Coverage status
Ovarian maintenance/recurrence and other gynecologic uses
Bevacizumab with paclitaxel + carboplatin; carboplatin + paclitaxel or docetaxel; oxaliplatin + docetaxel (with exclusions); used as maintenance; combined with PARP inhibitors (olaparib or niraparib) when BRCA/HR criteria met

Pediatric CNS indication	Bevacizumab use/regimen	Coverage status
Diffuse high-grade glioma (≤21 years), medulloblastoma (3–21 years), optic pathway glioma (<18 years), NF2 vestibular schwannomas (≥6 years)
Single-agent bevacizumab for palliation; as part of TEMR or MEMMAT regimens; in combination with standard therapies for age- and tumor-specific indications

Small bowel adenocarcinoma context	Bevacizumab combination/regimen	Coverage status
Advanced or metastatic small bowel adenocarcinoma
Bevacizumab combined with a fluoropyrimidine-based regimen (e.g., 5-FU or capecitabine); used as initial therapy if pMMR/MSS

Study / reference	Regimen involving bevacizumab	Tumor type / relevance
Hurwitz H et al. (2004)
Bevacizumab plus irinotecan, fluorouracil, and leucovorin
Metastatic colorectal cancer (supports FOLFIRI + bevacizumab)

Definitions and Clinical Terms

Actionable biomarkers (recommended testing)

Actionable biomarkers listEGFR, KRAS, ALK, ROS1, BRAF, NTRK1/2/3, MET, RET, NRG1, ERBB2 (HER2) — complete molecular testing recommended

Testing modalitiesMolecular assessment via tissue biopsy and/or plasma testing recommended

Clinical consequenceIdentify clinically actionable markers to guide targeted therapy in NSCLC and other tumor types as applicable

Epithelial subtypes

Epithelial subtypes enumeratedSerous, endometrioid, carcinosarcoma (MMMT of the ovary), clear cell, mucinous, and borderline epithelial (low malignant potential) tumors

Context of useHistology subtypes inform eligibility for neoadjuvant, adjuvant, and maintenance bevacizumab use in ovarian/fallopian tube/primary peritoneal cancer

Background and Clinical Context

Bevacizumab and its listed biosimilars are monoclonal antibodies that inhibit vascular endothelial growth factor (VEGF) and are used to reduce tumor angiogenesis across multiple solid tumor types. In clinical practice and per this policy, bevacizumab is administered intravenously and is commonly given in combination with cytotoxic chemotherapy or immunotherapy regimens (e.g., fluoropyrimidine‑based regimens in colorectal and appendiceal cancers; carboplatin/paclitaxel in gynecologic cancers; atezolizumab plus bevacizumab in selected hepatocellular carcinoma regimens), and in selected settings may be used as single‑agent therapy for CNS symptomatic indications or maintenance after combination therapy. The policy also defines universal requirements (age, recent bleeding or surgical wound precautions, and biosimilar step requirements) and indication‑specific combinations, dosing ranges, and prior authorization expectations to guide appropriate use.

OpenPayer

Bevacizumab (and listed biosimilars) — Intravenous oncology coverage and prior authorization criteria