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.

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.

• Renewal requires evidence the patient continues to meet universal and indication‑specific criteria including performance status and any required concomitant therapies.
• Confirm duration of authorization not exceeded (see Length of Authorization).
• Documentation must show disease response (stability or tumor decrease) unless the indication states otherwise.
• Document absence of unacceptable toxicity (examples include GI perforation/fistula, wound healing complications, necrotizing fasciitis, hemorrhage, ATE/VTE, uncontrolled hypertension, PRES, nephrotic syndrome/proteinuria, severe infusion reactions, ovarian failure, CHF).

Renewal Denial Triggers

Renewal requests may be denied for lack of disease response, unacceptable toxicity, or if the allowed duration of prior authorization has been exceeded.

• Denial triggers: no stabilization or tumor decrease as documented; evidence of unacceptable toxicity; authorization duration exceeded.

Therapy History and Testing Documentation

Therapy history and diagnostic testing must be documented when requesting initial or renewal authorization. Provide prior lines of therapy and relevant biomarker testing results per the indication.

• Example: CRC — document prior FOLFOX/CapeOX within 12 months when indicated and MMR/MSI testing per NCCN.
• Example: Ovarian — document BRCA1/2 status and homologous recombination deficiency testing when required; document prior use of bevacizumab if maintenance/continuation criteria apply.
• For vaginal/vulvar cancer, document PDL1 (CPS) status when pembrolizumab combinations are requested (use FDA‑approved or CLIA‑compliant assay).

Required Documentation for Renewal

Required documentation for renewal must demonstrate the member continues to meet universal and indication‑specific criteria, includes evidence of concomitant therapies where applicable, and supports clinical benefit and tolerability of continued therapy.

• Include clinical assessment showing disease response or stability per the indication.
• Include records of concomitant therapies (e.g., chemotherapy, PARP inhibitor, immunotherapy) when required by the indication.
• Include documentation of adverse events and rationale for continuing therapy if prior toxicity occurred.

Required Diagnosis Coding

Diagnosis coding: providers must submit an appropriate ICD‑10 diagnosis code from Appendix 1 that supports a covered indication when requesting prior authorization or submitting claims.

• Use one of the covered ICD‑10 codes listed in Appendix 1 (e.g., C18.*, C20, C34.*, C51-55 series, etc.).
• Submit the code that best reflects the treated primary site/indication and include supporting clinical documentation.

Medicare vs Non‑Medicare Guidance

Medicare vs Non‑Medicare Guidance. The preceding criteria are intended for non‑Medicare coverage determinations. Medicare Part B coverage follows CMS manuals and may be governed by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs); compliance with applicable NCDs/LCDs/LCAs is required for Medicare claims.

• For Medicare Part B, refer to Medicare Benefit Policy Manual (Pub. 100‑2), Chapter 15, §50 and search the CMS coverage database for applicable NCDs/LCDs/LCAs.
• Local contractor guidance (e.g., NCD/LCA/LCD A52370; contractor examples) may apply—confirm the beneficiary’s jurisdiction and applicable documents before authorization.
• Non‑Medicare determinations should follow the policy criteria in this document.

Prior Authorization: Consider

Consideration for Prior Authorization. Per the NQTL Factor Checklist, indication and drug cost support applying prior authorization to this agent; safety/efficacy factors did not indicate PA as a priority alone. Prior authorization should be considered when the indication and cost factors apply.

• NQTL assessment: Indication = Yes (consider PA); Cost of drug = Yes (consider PA); Safety/efficacy = No (PA not a priority solely for these factors).
• Use clinical criteria and cost considerations when determining whether to require PA for a specific request.

Combination and Sequencing Notes

Combination and sequencing notes: many gynecologic and vulvovaginal indications specify bevacizumab in combination with particular chemotherapy agents or with PARP inhibitors/immunotherapy; sequencing and combination requirements are indication specific and must be followed.

• Examples: Ovarian cancer — bevacizumab is described in combination with carboplatin + paclitaxel (or docetaxel) and may be used with olaparib or niraparib for maintenance in specific biomarker contexts.
• Vaginal/vulvar cancers — bevacizumab may be used with paclitaxel plus cisplatin/carboplatin/topotecan or with pembrolizumab combinations when PDL1 CPS ≥1.
• Follow indication‑specific sequencing (neoadjuvant, adjuvant, maintenance, or subsequent therapy) as specified in Section III.