Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Bevacizumab (Avastin) or a bevacizumab biosimilar (Mvasi, Zirabev, Alymsys, Vegzelma) may be considered medically necessary for individuals 18 years of age or older who meet
ANY ONE
of the following criteria:
Cervical Cancer
-
For the treatment of persistent, recurrent or metastatic cervical cancer in combination with
ONE
of the following:
-
Paclitaxel and cisplatin;
or
-
Paclitaxel and topotecan;
or
Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer
-
For treatment in
ANY
of the following:
-
In combination with carboplatin and paclitaxel, followed by bevacizumab (Avastin) as a single agent, for stage III or IV disease following initial surgical resection;
or
-
In combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan for individuals with platinum-resistant recurrent disease who received no more than two (2) prior chemotherapy regimens;
or
-
In combination with
ANY
of the following regimens, followed by bevacizumab (Avastin) as a single agent for platinum-sensitive recurrent disease:
-
In combination with carboplatin and paclitaxel;
or
-
In combination with carboplatin and gemcitabine;
or
Glioblastoma
-
For treatment of recurrent glioblastoma;
or
Hepatocellular Carcinoma
-
For the treatment of individuals with unresectable or metastatic hepatocellular carcinoma in combination with atezolizumab who have not received prior systemic therapy;
or
Metastatic Colorectal Cancer
-
In combination with intravenous 5-fluorouracil-based chemotherapy for first or second-line treatment;
or
-
As second-line treatment in individuals who have progressed on a first-line bevacizumab (Avastin)-containing regimen in
ONE
of the following:
-
In combination with fluoropyrimidine-irinotecan;
or
-
In combination with fluoropyrimidine-oxaliplatin;
or
Non-Squamous Non-Small Cell Lung Cancer (NSCLC)
-
In combination with carboplatin and paclitaxel as first-line treatment of individuals with unresectable, locally advanced, recurrent or metastatic non-squamous cell type NSCLC;
or
Renal Cell Carcinoma
- For treatment of metastatic renal cell carcinoma in combination with interferon alfa.
Compendia Sources
Bevacizumab (Avastin) and bevacizumab biosimilars (Mvasi, Zirabev Alymsys, Vegzelma) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of bevacizumab (Avastin) and bevacizumab biosimilars (Mvasi, Zirabev, Alymsys, Vegzelma) for any other oncologic indication
not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Codes
| J9035 | Q5107 | Q5118 | Q5126 | Q5129 |
