Asset Publisher

vp-0014

print Print Back Back

Bevacizumab: Avastin®; Mvasi®; Zirabev™; Alymsys®; Vegzelma® *ONCOLOGY*

Policy Number: VP-0014

 

Intravenous                                  *ONCOLOGY*

 

Last Review Date: 12/07/2023

Date of Origin: 10/17/2008

Dates Reviewed: 06/2009, 12/2009, 03/2010, 06/2010, 09/2010, 12/2010, 02/2011, 03/2011, 06/2011, 09/2011, 12/2011, 03/2011, 06/2012, 09/2012, 12/2012, 02/2013, 03/2013, 06/2013, 08/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 05/2015, 08/2015, 11/2015, 02/2016, 05/2016, 08/2016, 11/2016, 12/2016, 02/2017, 05/2017, 08/2017, 11/2017, 02/2018, 05/2018, 09/2018, 12/2018, 03/2019, 06/2019, 09/2019, 12/2019, 03/2020, 06/2020, 09/2020, 12/2020, 03/2021, 06/2021, 09/2021, 12/2021, 03/2022, 05/2022, 09/2022, 11/2022, 03/2023, 06/2023, 09/2023, 12/2023

FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill.

  1. Length of Authorization 8

Coverage will be provided for 6 months and may be renewed (unless otherwise specified).

  • Adult CNS Cancers (symptom management): Coverage will be provided for twelve (12) weeks and may NOT be renewed.
  1. Dosing Limits
  1. Quantity Limit (max daily dose) [NDC Unit]:

Avastin, Mvasi, Zirabev, Alymsys, Vegzelma:

  • 100 mg/4 mL single-dose vial: 3 vials 21 days
  • 400 mg/16 mL single-dose vial: 4 vials per 21 days
  1. Max Units (per dose and over time) [HCPCS Unit]:

Oncology indications (J9035/Q5107/Q5118/Q5126/Q5129):

  • CRC & Appendiceal Adenocarcinoma, CNS Cancers, RCC:
    • 120 billable units per 14 days
  • Small Bowel Adenocarcinoma & Ampullary Adenocarcinoma:
    • 90 billable units per 14 days
  • NSCLC, Cervical Cancer, HCC, Vulvar Cancer, MPM, & MPeM:
    • 170 billable units per 21 days
  • All other indications:
    • 170 billable units per 14 days
  1. Initial Approval Criteria 1-5

Coverage is provided in the following conditions:

For PEEHIP Members Only

  • Zirabev (bevacizumab-bvzr) is the preferred product and all other bevacizumab products are non-preferred. Patient must have tried and had an inadequate response or intolerance to, or a contraindication to Zirabev, attributable to the biosimilar formulation, prior to consideration of a non-preferred bevacizumab product OR the patient is continuing treatment with a non-preferred product; AND

For Commercial Members Only

  • Zirabev (bevacizumab-bvzr) and Mvasi (bevacizumab-awwb) are the preferred products. Patient must have tried and had an inadequate response or intolerance to, or a contraindication to Zirabev and Mvasi, attributable to the biosimilar formulation, prior to consideration of a non-preferred bevacizumab product including Avastin (bevacizumab). Members currently on non-preferred therapies may complete their current course of treatment for the duration of the current precertification period; upon precertification renewal or restarting therapy, transition to a preferred product is required; AND
  • Patient is at least 18 years of age, unless otherwise specified; AND

Universal Criteria 1-5

  • Patient has no recent history of hemoptysis (i.e., the presence of ≥2.5 mL of blood in sputum); AND
  • Patient must not have had a surgical procedure within the preceding 28 days or have a surgical wound that has not fully healed; AND

Ampullary Adenocarcinoma ‡ 6

  • Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) based regimen for intestinal type disease; AND
    • Used as first-line therapy for unresectable localized or metastatic disease; OR
    • Used as subsequent therapy for disease progression; AND
  • Patient has poor performance status (ECOG PS 2); OR
  • Patient has good performance status (ECOG 0-1, with good biliary drainage and adequate nutritional intake) and received prior oxaliplatin-based therapy

Adult Central Nervous System (CNS) Cancers † ‡ Ф 1-6,8,27,28

  • Used as single-agent short-course therapy for symptom management related to radiation necrosis, poorly controlled vasogenic edema, or mass effect; AND
    • Patient has a diagnosis of one of the following CNS cancers :
    • Circumscribed Glioma
    • Primary CNS Lymphoma
    • Meningiomas
    • Brain or Spine metastases
    • Medulloblastoma
    • Glioblastoma/Gliosarcoma/H3-mutated high-grade glioma
    • IDH-mutant Astrocytoma (WHO Grade 2-4)
    • IDH-mutant, 1p19q codeleted Oligodendroglioma (WHO Grade 2 or 3)
    • Intracranial or Spinal Ependymoma (excluding subependymoma); OR
  • Used for recurrent or progressive disease; AND
    • Patient has a diagnosis of one of the following CNS cancers:
      • IDH-mutant, 1p19q codeleted Oligodendroglioma (WHO Grade 3)
      • Glioblastoma/Gliosarcoma/H3-mutated high-grade glioma † ‡
      • IDH-mutant Astrocytoma (WHO Grade 3 or 4) ; AND 
    • Used as a single agent; OR
    • Used in combination with carmustine, lomustine, or temozolomide; AND
      • Patient has failed bevacizumab monotherapy; OR
    • Used as a single agent for Intracranial or Spinal Ependymoma (excluding subependymoma) after prior radiation therapy ; OR
    • Used as a single agent for surgically inaccessible Meningiomas when radiation is not possible

     Cervical Cancer † ‡ 1-6,30,49

  • Patient has persistent, recurrent, or metastatic disease; AND
    • Disease has adenocarcinoma, adenosquamous, or squamous cell carcinoma histology; AND
  • Used in combination with paclitaxel AND either cisplatin, carboplatin, or topotecan; OR
  • Used in combination with pembrolizumab, paclitaxel, AND cisplatin or carboplatin; AND
            • Tumor expresses PD-L1 (Combined Positive Score [CPS] ≥1) as determined by an FDA-approved or CLIA compliant testv; OR
  • Used as a single agent as subsequent therapy; OR
    • Patient has small cell neuroendocrine carcinoma of the cervix (NECC); AND
  • Used in combination with paclitaxel and topotecan; OR
  • Used as a single agent as subsequent therapy

Colorectal Cancer (CRC) † ‡ 1-6,19-24,50

  • Will not be used as part of adjuvant treatment; AND
  • Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) or irinotecan-based regimen as first-line or subsequent therapy for metastatic, unresectable (or medically inoperable), or advanced disease; AND
  • Patient has mismatch repair proficient/microsatellite-stable (pMMR/MSS) disease; OR
  • Patient has mismatch repair deficient/microsatellite instability-high (dMMR/MSI-H) disease AND is not a candidate for or has progressed on checkpoint inhibitor immunotherapy; OR
  • Used in combination with a fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based regimen (not used first line) as second-line therapy for metastatic disease that has progressed on a first-line bevacizumab-containing regimen ; OR
  • Used in combination with trifluridine and tipiracil as subsequent therapy for advanced or metastatic disease; AND
  • Patient progressed through all available regimens (e.g., oxaliplatin-based therapy, irinotecan-based therapy, fluoropyrimidine-based therapy, etc.)*; AND
            • Patient has mismatch repair proficient/microsatellite-stable (pMMR/MSS) disease**; OR
            • Patient has mismatch repair deficient/microsatellite instability-high (dMMR/MSI-H) disease** AND is not a candidate for or has progressed on checkpoint inhibitor immunotherapy**

*Refer to NCCN Colon and Rectal Cancer guidelines for regimens.

**Note: Only applies to advanced disease.

Appendiceal Adenocarcinoma – Colon Cancer ‡ 6,47

  • Used as initial therapy for advanced or metastatic disease; AND
    • Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) based regimen; AND
  • Patient has mismatch repair proficient/microsatellite-stable (pMMR/MSS) disease; OR
  • Patient has mismatch repair deficient/microsatellite instability-high (dMMR/MSI-H) disease AND is not a candidate for or has progressed on checkpoint inhibitor immunotherapy; OR
  • Used as subsequent therapy for progression of advanced or metastatic disease; AND
    • Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) or irinotecan-based regimen following previous oxaliplatin-, irinotecan-, and/or fluoropyrimidine-based therapy; AND
  • Patient has mismatch repair proficient/microsatellite-stable (pMMR/MSS) disease; OR
  • Patient has mismatch repair deficient/microsatellite instability-high (dMMR/MSI-H) disease AND is not a candidate for or has progressed on checkpoint inhibitor immunotherapy; OR
    • Used in combination with trifluridine and tipiracil; AND
  • Patient progressed through all available regimens (e.g., oxaliplatin-based therapy, irinotecan-based therapy, therapy without irinotecan or oxaliplatin, etc.)*; AND
            • Patient has mismatch repair proficient/microsatellite-stable (pMMR/MSS) disease; OR
            • Patient has mismatch repair deficient/microsatellite instability-high (dMMR/MSI-H) disease AND is not a candidate for or has progressed on checkpoint inhibitor immunotherapy

*Refer to NCCN Colon Cancer guidelines for regimens.

Endometrial Carcinoma (Uterine Neoplasms) ‡ 6,37

  • Used as a single agent for recurrent disease that has progressed on prior cytotoxic chemotherapy; OR
  • Used in combination with carboplatin and paclitaxel for recurrent disease

Hepatocellular Carcinoma (HCC) †Ф 1,6,16,17  

  • Used as first-line therapy in combination with atezolizumab; AND
  • Patient has Child-Pugh Class A hepatic impairment; AND
  • Patient has unresectable or metastatic disease; OR
  • Patient has liver-confined disease that is inoperable by performance status, comorbidity, or with minimal or uncertain extrahepatic disease; OR
  • Patient has extensive liver tumor burden; OR
  • Patient has Child-Pugh Class B hepatic impairment; AND
  • Patient has unresectable disease and is not a transplant candidate; OR
  • Patient has metastatic disease; OR
  • Patient has liver-confined disease that is inoperable by performance status, comorbidity, or with minimal or uncertain extrahepatic disease; OR
  • Patient has extensive liver tumor burden

Malignant Peritoneal* Mesothelioma (MPeM) ‡ 6,44,51

  • Used as first-line therapy; AND
  • Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible) for unresectable diffuse or recurrent disease; OR
  • Used as subsequent therapy; AND
  • Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible); AND
  • Immunotherapy was administered as first-line treatment; OR
  • Used as a rechallenge if pemetrexed-based treatment was administered first-line with good response; OR
  • Used in combination with atezolizumab; AND
  • Patient has not received previous therapy with immune checkpoint inhibitors (e.g., nivolumab, pembrolizumab, durvalumab, avelumab, cemiplimab, dostarlimab, nivolumab/relatlimab-rmbw, retifanlimab, etc.)

*Note: May also be used for pericardial mesothelioma and tunica vaginalis testis mesothelioma.

Malignant Pleural* Mesothelioma (MPM) ‡ 6,39,51

  • Used as first-line therapy; AND
  • Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible); OR
  • Used as subsequent therapy; AND
  • Used in combination with pemetrexed AND either cisplatin or carboplatin (if cisplatin ineligible); AND
  • Immunotherapy was administered as first-line treatment; OR
  • Used as a rechallenge if pemetrexed-based treatment was administered first-line with good response

*Note: May also be used for pericardial mesothelioma and tunica vaginalis testis mesothelioma.

Non-Squamous Non-Small Cell Lung Cancer (NSCLC) 1-6,12,14,15,25,26

  • Used for recurrent, advanced, or metastatic disease (excluding locoregional recurrence or symptomatic local disease with no evidence of disseminated disease) or mediastinal lymph node recurrence with prior radiation therapy; AND
  • Used as first-line therapy; AND
  • Used in combination with erlotinib for EGFR exon 19 deletion or exon 21 L858R mutations; OR
  • Used for one of the following:
  • Patients with a performance status (PS) 0-1 who have tumors that are negative for actionable molecular biomarkers* and PD-L1 expression < 1%
  • PD-L1 expression positive (PD-L1 ≥ 1%) tumors that are negative for actionable molecular biomarkers*
  • Patients with a PS 0-1 who are positive for one of the following molecular biomarkers: EGFR exon 20, KRAS G12C, BRAF V600E, NTRK1/2/3 gene fusion, MET exon 14 skipping, RET rearrangement, or ERBB2 (HER2); AND
  • Used in combination with one of the following:
  • Carboplatin and paclitaxel
  • Pemetrexed and either carboplatin or cisplatin in patients with contraindications¥ to PD-1 or PD-L1 inhibitors
  • Atezolizumab, carboplatin, and paclitaxel; OR
  • Used as subsequent therapy in patients with a PS 0-1; AND
  • Used for one of the following:
  • EGFR exon 19 deletion or exon 21 L858R mutation, EGFR S768I, L861Q, and/or G719X mutation, ALK rearrangement, or ROS1 rearrangement positive tumors AND patient received prior targeted therapy§ for those aberrations
  • BRAF V600E mutation, NTRK1/2/3 gene fusion, MET exon 14 skipping mutation, or RET rearrangement positive tumors
  • PD-L1 expression positive (PD-L1 ≥ 1%) tumors that are negative for actionable molecular biomarkers* after prior PD-1/PD-L1 inhibitor therapy but no prior platinum-containing chemotherapy; AND
  • Used in combination with one of the following:
            • Carboplatin and paclitaxel in patients with contraindications¥ to PD-1 or PD-L1 inhibitors
            • Pemetrexed and either carboplatin or cisplatin in patients with contraindications¥ to PD-1 or PD-L1 inhibitors
            • Atezolizumab, carboplatin, and paclitaxel (excluding use in patients who have received prior PD-1/PD-L1 inhibitor therapy); OR
  • Used as continuation maintenance therapy in patients who achieved a tumor response or stable disease after first-line systemic therapy; AND
  • Used as a single agent (bevacizumab must have been included in the first-line regimen); OR
  • Used in combination with pemetrexed following a first-line bevacizumab/pemetrexed/platinum chemotherapy regimen; OR
  • Used in combination with atezolizumab following a first-line atezolizumab/carboplatin/paclitaxel/bevacizumab regimen; OR
  • Used as continuation of therapy following disease progression on erlotinib with bevacizumab; AND
  • Patient has asymptomatic disease, symptomatic brain lesions, or symptomatic systemic limited progression; AND
  • Patient has T790M negative disease

* Note: Actionable molecular genomic biomarkers include EGFR, KRAS, ALK, ROS1, BRAF, NTRK1/2/3, MET, RET, and ERBB2 (HER2). If there is insufficient tissue to allow testing for all of EGFR, KRAS, ALK, ROS1, BRAF, NTRK1/2/3, MET, RET, and ERBB2 (HER2), repeat biopsy and/or plasma testing should be done. If these are not feasible, treatment is guided by available results and, if unknown, these patients are treated as though they do not have driver oncogenes.

¥ Note: Contraindications for treatment with PD-1/PD-L1 inhibitors may include active or previously documented autoimmune disease and/or current use of immunosuppressive agents, and some oncogenic drivers (i.e., EGFR exon 19 deletion or exon 21 L858R, ALK rearrangements) have been shown to be associated with less benefit from PD-1/PD-L1 inhibitors.

Ovarian, Fallopian Tube, and Primary Peritoneal Cancer † ‡ Ф 1-6,13,31-34,52

  • Patient has malignant stage II-IV sex cord-stromal tumors ; AND
    • Used as a single agent for clinically relapsed disease; OR
  • Patient has epithelial* ovarian, fallopian tube, or primary peritoneal cancer ; AND
    • Patient has persistent or recurrent disease; AND
  • Bevacizumab has not been used previously; AND
  • Patient is not experiencing an immediate biochemical relapse (i.e., rising CA-125 without radiographic evidence of disease); AND
            • Patient has platinum-sensitive disease; AND
  • Used as a single agent; OR
  • Used in combination with carboplatin AND either gemcitabine, paclitaxel or liposomal doxorubicin; OR
            • Patient has platinum-resistant disease; AND  
  • Used as a single agent; OR
  • Used in combination with one of the following: oral cyclophosphamide, gemcitabine, liposomal doxorubicin, paclitaxel, or topotecan ; OR
  • Used in combination with carboplatin AND either gemcitabine, paclitaxel or liposomal doxorubicin; AND
    • Patient does not have platinum-refractory disease; OR
        • Used in combination with paclitaxel and carboplatin for rising CA-125 levels or clinical relapse in patients who have received no prior chemotherapy (mucinous, clear cell, carcinosarcoma, endometrioid, and serous histology only); OR
    • Used as maintenance therapy; AND
  • Used for stage II-IV disease following primary therapy including bevacizumab; AND
            • Used as a single agent in patients that are BRCA1/2 wild-type or unknown AND homologous recombination (HR) proficient, HR deficient, or status unknown (grade 2/3 endometrioid and high-grade serous histology only); OR
            • Used in combination with olaparib; AND
  • Patient is BRCA1/2 wild-type or unknown AND HR deficient (grade 2/3 endometrioid and high-grade serous histology only); OR
  • Patient has a germline or somatic BRCA1/2 mutation (grade 2/3 endometrioid, high-grade serous, clear cell, carcinosarcoma histology only); OR
  • Used as a single agent following recurrence therapy with chemotherapy plus bevacizumab for platinum-sensitive disease; OR
  • Used as continued treatment for stable disease following neoadjuvant therapy (endometrioid and serous histology only); AND
            • Used in combination with carboplatin AND paclitaxel or docetaxel; OR
            • Used in combination with oxaliplatin and docetaxel; OR
    • Used as neoadjuvant therapy (endometrioid and serous histology only); AND
  • Used in combination with one of the following:
            • Carboplatin AND paclitaxel or docetaxel
            • Oxaliplatin and docetaxel; AND
  • Patient is a poor surgical candidate or has a low likelihood of optimal cytoreduction; OR
    • Used as adjuvant therapy; AND
  • Used in combination with oxaliplatin and docetaxel; AND
            • Patient has pathologic stage IB or IC disease (clear cell, carcinosarcoma, grade 2/3 endometrioid, and high-grade serous histology only); OR
            • Patient has pathologic stage II-IV disease (mucinous, clear cell, carcinosarcoma, endometrioid, and serous histology only); OR
            • Used following interval debulking surgery (IDS) in patients with a response or stable disease to neoadjuvant therapy (endometrioid and serous histology only); AND
            • Patient is a poor surgical candidate or has a low likelihood of optimal cytoreduction; OR
  • Used in combination with carboplatin AND paclitaxel or docetaxel; AND
            • Patient has pathologic stage II-IV disease (mucinous, clear cell, carcinosarcoma, borderline epithelial, endometrioid, and serous histology only); OR
            • Used following interval debulking surgery (IDS) in patients with a response or stable disease to neoadjuvant therapy (endometrioid and serous histology only); AND
            • Patient is a poor surgical candidate or has a low likelihood of optimal cytoreduction

* Epithelial subtypes include serous, endometrioid, carcinosarcoma (malignant mixed Müllerian tumors [MMMTs] of the ovary), clear cell, mucinous, and borderline epithelial tumors (also known as low malignant potential [LMP] tumors).

Pediatric Central Nervous System (CNS) Cancers 2,47

  • Patient is ≤ 18 years of age; AND
  • Patient has diffuse high-grade glioma (excluding oligodendroglioma, IDH-mutant and 1p/19q co-deleted or astrocytoma IDH-mutant); AND
  • Used for palliation of recurrent or progressive disease

Renal Cell Carcinoma (RCC) † Ф 1-6,29

  • Used in combination with interferon alfa for metastatic disease ; OR
  • Patient has relapsed or metastatic disease with non-clear cell histology; AND
  • Used as a single agent ; OR
  • Used in combination with everolimus ; OR
  • Used in combination with erlotinib for advanced papillary disease including hereditary leiomyomatosis and renal cell carcinoma (HLRCC)-associated RCC

Small Bowel Adenocarcinoma 6,18

  • Patient has advanced or metastatic disease; AND
  • Used in combination with a fluoropyrimidine- (e.g., 5-fluorouracil/5-FU or capecitabine) based regimen

Soft Tissue Sarcoma ‡ 6

  • Used as a single agent for angiosarcoma; OR
  • Used in combination with temozolomide for solitary fibrous tumor

Vulvar Cancer 6

  • Used in combination with paclitaxel and cisplatin; AND
  • Patient has squamous cell carcinoma or adenocarcinoma; AND
  • Patient has advanced, recurrent, or metastatic disease

v If confirmed using an FDA-approved assay – http://www.fda.gov/companiondiagnostics

FDA Approved Indication(s); Compendia Recommended Indication(s); Ф Orphan Drug

§ Genomic Aberration/Mutational Driver Targeted Therapies 12

(Note: not all inclusive, refer to guidelines for appropriate use)

Sensitizing EGFR mutation-positive tumors

ALK rearrangement-positive tumors

ROS1 rearrangement-positive tumors

BRAF V600E-mutation positive tumors

NTRK1/2/3 gene fusion positive tumors

  • Afatinib
  • Erlotinib
  • Dacomitinib
  • Gefitinib
  • Osimertinib
  • Amivantamab

(exon-20 insertion)

  • Alectinib
  • Brigatinib
  • Ceritinib
  • Crizotinib
  • Lorlatinib
  • Ceritinib
  • Crizotinib 
  • Entrectinib
  • Lorlatinib
  • Dabrafenib ± trametinib
  • Encorafenib + binimetinib
  • Vemurafenib
  • Larotrectinib
  • Entrectinib

PD-L1 tumor expression ≥ 1%

MET exon-14 skipping mutations

RET rearrangement-positive tumors

KRAS G12C mutation positive tumors

ERBB2 (HER2) mutation positive tumors

  • Pembrolizumab
  • Atezolizumab
  • Nivolumab + ipilimumab
  • Cemiplimab
  • Tremelimumab + durvalumab
  • Capmatinib
  • Crizotinib
  • Tepotinib
  • Selpercatinib
  • Cabozantinib
  • Pralsetinib
  • Sotorasib
  • Adagrasib
  • Fam-trastuzumab deruxtecan-nxki
  • Ado-trastuzumab emtansine
  1. Renewal Criteria 1-6,8

Coverage may be renewed based upon the following criteria:

  • Patient continues to meet the universal and other indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc. identified in section III; AND
  • Disease response with treatment as defined by stabilization of disease or decrease in size of tumor or tumor spread; AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: gastrointestinal perforations and fistulae, surgical/wound healing complications, necrotizing fasciitis, hemorrhage, arterial and venous thromboembolic events (ATE & VTE), uncontrolled hypertension, posterior reversible encephalopathy syndrome (PRES), nephrotic syndrome, proteinuria, severe infusion-related reactions, ovarian failure, congestive heart failure (CHF), etc.; AND

Adult CNS Cancers – symptom management (short-course therapy):

  • Coverage may NOT be renewed

Adult CNS Cancers (in combination with carmustine, lomustine, or temozolomide):

  • Refer to Section III for criteria

Colorectal Cancer (after first-line bevacizumab-containing regimen):

  • Refer to Section III for criteria

MPeM (combination therapy with atezolizumab):

  • Refer to Section III for criteria

Non-Squamous Non-Small Cell Lung Cancer (maintenance therapy OR continuation therapy in combination with erlotinib):

  • Refer to Section III for criteria

Ovarian Cancer (maintenance therapy):

  • Refer to Section III for criteria
  1. Dosage/Administration 1-4,7,8,13,18,30,36,37,39-48

Indication

Dose

CRC & Appendiceal Adenocarcinoma

Administer 5 to 10 mg/kg intravenously every 2 weeks OR 7.5 mg/kg intravenously every 3 weeks until disease progression or unacceptable toxicity.

Small Bowel Adenocarcinoma & Ampullary Adenocarcinoma

Administer 5 mg/kg intravenously every 2 weeks OR 7.5 mg/kg intravenously every 3 weeks until disease progression or unacceptable toxicity.

NSCLC, Cervical Cancer, HCC, Vulvar Cancer, MPM, & MPeM

Administer 15 mg/kg intravenously every 3 weeks until disease progression or unacceptable toxicity.

Adult CNS Cancers

For disease treatment:

  • Administer 10 mg/kg intravenously every 2 weeks until disease progression or unacceptable toxicity.

For symptom management:

  • Administer 5 to 10 mg/kg intravenously every 2 weeks up to 12 weeks duration OR 7.5 mg/kg intravenously every 3 weeks up to 12 weeks.

Pediatric CNS Cancers & RCC

Administer 10 mg/kg intravenously every 2 weeks until disease progression or unacceptable toxicity.

All Other Indications

Administer 5 to 10 mg/kg intravenously every 2 weeks OR 7.5 to 15 mg/kg intravenously every 3 weeks until disease progression or unacceptable toxicity.

  1. Billing Code/Availability Information

HCPCS Code(s):

  • 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, biosimilar, (vegzelma), 10 mg; 1 billable unit = 10 mg

NDC(s):

  • Avastin single-dose vial, 100 mg/4 mL solution for injection: 50242-0060-xx
  • Avastin single-dose vial, 400 mg/16 mL solution for injection: 50242-0061-xx
  • Mvasi single-dose vial, 100 mg/4 mL solution for injection: 55513-0206-xx
  • Mvasi single-dose vial, 400 mg/16 mL solution for injection: 55513-0207-xx
  • Zirabev single-dose vial, 100 mg/4 mL solution for injection: 00069-0315-xx
  • Zirabev single-dose vial, 400 mg/16 mL solution for injection: 00069-0342-xx
  • Alymsys single-dose vial, 100 mg/4 mL solution for injection: 70121-1754-xx
  • Alymsys single-dose vial, 400 mg/16 mL solution for injection: 70121-1755-xx
  • Vegzelma single-dose vial, 100 mg/4 mL solution for injection: 72606-0011-xx
  • Vegzelma single-dose vial, 400 mg/16 mL solution for injection: 72606-0012-xx
  1. References
  1. Avastin [package insert]. South San Francisco, CA; Genentech, Inc.; September 2022. Accessed November 2023.
  2. Mvasi [package insert]. Thousand Oaks, CA; Amgen, Inc.; February 2023. Accessed November 2023.
  3. Zirabev [package insert]. New York, NY; Pfizer, Inc.; February 2023. Accessed November 2023.
  4. Alymsys [package insert]. Bridgewater, NJ; Amneal Pharmaceuticals LLC; April 2022. Accessed November 2023.
  5. Vegzelma [package insert]. Incheon, Republic of Korea; Celltrion, Inc.; February 2023. Accessed November 2023.
  6. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) bevacizumab. National Comprehensive Cancer Network, 2023. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed November 2023.
  7. Ceresoli GL, Zucali PA, Mencoboni M, et al. Phase II study of pemetrexed and carboplatin plus bevacizumab as first-line therapy in malignant pleural mesothelioma. Br J Cancer. 2013 Aug 6; 109(3): 552–558
  8. Delishaj D, Ursino S, Pasqualetti F, et al. Bevacizumab for the Treatment of Radiation-Induced Cerebral Necrosis: A Systematic Review of the Literature. J Clin Med Res. 2017 Apr; 9(4): 273–280.
  9. Fahrenbruch R, Kintzel P, Bott AM, et al. Dose Rounding of Biologic and Cytotoxic Anticancer Agents: A Position Statement of the Hematology/Oncology Pharmacy Association. J Oncol Pract. 2018 Mar;14(3):e130-e136.
  10. Hematology/Oncology Pharmacy Association (2019). Intravenous Cancer Drug Waste Issue Brief. Retrieved from http://www.hoparx.org/images/hopa/advocacy/Issue-Briefs/Drug_Waste_2019.pdf
  11. Bach PB, Conti RM, Muller RJ, et al. Overspending driven by oversized single dose vials of cancer drugs. BMJ. 2016 Feb 29;352:i788.
  12. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Non-Small Cell Lung Cancer 4.2023. National Comprehensive Cancer Network, 2023. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Guidelines, go online to NCCN.org. Accessed November 2023.
  13. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Ovarian Cancer/Fallopian Tube Cancer/Primary Peritoneal Cancer 2.2023. National Comprehensive Cancer Network, 2023. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Guidelines, go online to NCCN.org. Accessed November 2023.
  14. Thatcher N, Goldschmidt JH, Thomas M, et al. Efficacy and safety of biosimilar ABP 215 compared with bevacizumab in patients with advanced nonsquamous non-small cell lung cancer (MAPLE): a randomized, double-blind, phase III study. Clin Cancer Res. 2019;25:2088-2095.
  15. Reinmuth N, Bryl M, Bondarenko I, et al. PF-06439535 (a Bevacizumab Biosimilar) Compared with Reference Bevacizumab (Avastin®), Both Plus Paclitaxel and Carboplatin, as First-Line Treatment for Advanced Non-Squamous Non-Small-Cell Lung Cancer: A Randomized, Double-Blind Study. BioDrugs. 2019 Oct;33(5):555-570. Doi: 10.1007/s40259-019-00363-4.
  16. Cheng AL, Qin S, Ikeda M, et al. LBA3-IMBrave150: Efficacy and safety results from a ph III study evaluating atezolizumab (atezo) + bevacizumab (bev) vs sorafenib (Sor) as first treatment (tx) for patients (pts) with unresectable hepatocellular carcinoma (HCC). Ann Oncol. 2019 Nov;30 Suppl 9:ix186-ix187.
  17. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Hepatocellular Carcinoma 2.2023. National Comprehensive Cancer Network, 2023. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Guidelines, go online to NCCN.org. Accessed November 2023.
  18. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Small Bowel Adenocarcinoma 1.2023. National Comprehensive Cancer Network, 2023. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Guidelines, go online to NCCN.org. Accessed November 2023.
  19. Hurwitz H, Fehrenbacher L, Novotny W, et al. Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. N Engl J Med. 2004 Jun 3;350(23):2335-42.
  20. Giantonio BJ, Catalano PJ, Meropol NJ, et al. Bevacizumab in combination with oxaliplatin, fluorouracil, and leucovorin (FOLFOX4) for previously treated metastatic colorectal cancer: results from the Eastern Cooperative Oncology Group Study E3200. J Clin Oncol. 2007;25(12):1539-1544.
  21. Chen HX, Mooney M, Boron M, et al. Phase II multicenter trial of bevacizumab plus fluorouracil and leucovorin in patients with advanced refractory colorectal cancer: an NCI Treatment Referral Center Trial TRC-0301. J Clin Oncol. 2006;24(21):3354-3360. Doi:10.1200/JCO.2005.05.1573.
  22. Bennouna J, Sastre J, Arnold D, et al. Continuation of bevacizumab after first progression in metastatic colorectal cancer (ML18147): a randomised phase 3 trial. Lancet Oncol. 2013 Jan;14(1):29-37.
  23. de Gramont A, Van Cutsem E, Schmoll HJ, et al. Bevacizumab plus oxaliplatin-based chemotherapy as adjuvant treatment for colon cancer (AVANT): a phase 3 randomised controlled trial. Lancet Oncol. 2012;13(12):1225-1233. Doi:10.1016/S1470-2045(12)70509-0.
  24. Allegra CJ, Yothers G, O’Connell MJ, et al. Phase III trial assessing bevacizumab in stages II and III carcinoma of the colon: results of NSABP protocol C-08. J Clin Oncol. 2011;29(1):11-16. Doi:10.1200/JCO.2010.30.0855.
  25. Sandler A, Gray R, Perry MC, et al. Paclitaxel-carboplatin alone or with bevacizumab for non-small-cell lung cancer. N Engl J Med. 2006 Dec 14;355(24):2542-50.
  26. Reck M, von Pawel J, Zatloukal P, et al. Phase III trial of cisplatin plus gemcitabine with either placebo or bevacizumab as first-line therapy for nonsquamous non-small-cell lung cancer: AVAil. J Clin Oncol. 2009 Mar 10;27(8):1227-34.
  27. Wick W, Gorlia T, Bendszus M, et al. Lomustine and Bevacizumab in Progressive Glioblastoma. N Engl J Med 2017; 377:1954-1963.
  28. Friedman HS, Prados MD, Wen PY, et al. Bevacizumab alone and in combination with irinotecan in recurrent glioblastoma. J Clin Oncol. 2009 Oct 1;27(28):4733-40.
  29. Escudier B, Pluzanska A, Koralewski P, et al. Bevacizumab plus interferon alfa-2a for treatment of metastatic renal cell carcinoma: a randomised, double-blind phase III trial. Lancet. 2007;370(9605):2103-2111. Doi:10.1016/S0140-6736(07)61904-7.
  30. Tewari KS, Sill MW, Penson RT, et al. Bevacizumab for advanced cervical cancer: final overall survival and adverse event analysis of a randomised, controlled, open-label, phase 3 trial (Gynecologic Oncology Group 240). Lancet. 2017;390(10103):1654-1663. Doi:10.1016/S0140-6736(17)31607-0.
  31. Burger RA, Brady MF, Bookman MA, et al. Incorporation of bevacizumab in the primary treatment of ovarian cancer. N Engl J Med. 2011 Dec 29;365(26):2473-83.
  32. Pujade-Lauraine E, Hilpert F, Weber B, et al. Bevacizumab Combined With Chemotherapy for Platinum-Resistant Recurrent Ovarian Cancer: The AURELIA Open-Label Randomized Phase III Trial. Journal of Clinical Oncology 2014 32:13, 1302-1308.
  33. Aghajanian C, Blank SV, Goff BA, et al. OCEANS: a randomized, double-blind, placebo-controlled phase III trial of chemotherapy with or without bevacizumab in patients with platinum-sensitive recurrent epithelial ovarian, primary peritoneal, or fallopian tube cancer. J Clin Oncol. 2012;30(17):2039–2045.
  34. Coleman RL, Brady MF, Herzog TJ, et al. Bevacizumab and paclitaxel-carboplatin chemotherapy and secondary cytoreduction in recurrent, platinum-sensitive ovarian cancer (NRG Oncology/Gynecologic Oncology Group study GOG-0213): a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol. 2017;18(6):779–791.
  35. Robert NJ, Diéras V, Glaspy J, et al. RIBBON-1: randomized, double-blind, placebo-controlled, phase III trial of chemotherapy with or without bevacizumab for first-line treatment of human epidermal growth factor receptor 2-negative, locally recurrent or metastatic breast cancer. J Clin Oncol. 2011 Apr 1;29(10):1252-60.
  36. Agulnik M, Yarber JL, Okuno SH, et al. An open-label, multicenter, phase II study of bevacizumab for the treatment of angiosarcoma and epithelioid hemangioendotheliomas. Ann Oncol. 2013;24(1):257-263. Doi:10.1093/annonc/mds237.
  37. Lorusso D, Ferrandina G, Colombo N, et al. Randomized phase II trial of carboplatin-paclitaxel (CP) compared to carboplatin-paclitaxel-bevacizumab (CP-B) in advanced (stage III-IV) or recurrent endometrial cancer: The MITO END-2 trial. Journal of Clinical Oncology 2015 33:15_suppl, 5502-5502.
  38. Miller K, Wang M, Gralow J, et al. Paclitaxel plus bevacizumab versus paclitaxel alone for metastatic breast cancer. N Engl J Med. 2007 Dec 27;357(26):2666-76.
  39. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Mesothelioma: Pleural 1.2023. National Comprehensive Cancer Network, 2023. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Guidelines, go online to NCCN.org. Accessed November 2023.
  40. Zalcman G, Mazieres J, Margery J, et al; French Cooperative Thoracic Intergroup (IFCT). Bevacizumab for newly diagnosed pleural mesothelioma in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS): a randomised, controlled, open-label, phase 3 trial. Lancet. 2016 Apr 2;387(10026):1405-1414.
  41. Park MS, Patel SR, Ludwig JA, et al. Activity of temozolomide and bevacizumab in the treatment of locally advanced, recurrent, and metastatic hemangiopericytoma and malignant solitary fibrous tumor. Cancer. 2011 Nov 1;117(21):4939-47. Doi: 10.1002/cncr.26098.
  42. Rose PG, Ali S, Moslemi-Kebria M, et al. Paclitaxel, Carboplatin, and Bevacizumab in Advanced and Recurrent Endometrial Carcinoma. Int J Gynecol Cancer. 2017 Mar;27(3):452-458. Doi: 10.1097/IGC.0000000000000891.
  43. Aghajanian C, Sill MW, Darcy KM, et al. Phase II trial of bevacizumab in recurrent or persistent endometrial cancer: a Gynecologic Oncology Group study. J Clin Oncol. 2011 Jun 1;29(16):2259-65. Doi: 10.1200/JCO.2010.32.6397.
  44. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Mesothelioma: Peritoneal 2.2023. National Comprehensive Cancer Network, 2023. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Guidelines, go online to NCCN.org. Accessed November 2023.
  45. Raghav KPS, Overman MJ, Liu S, et al. A phase II trial of atezolizumab and bevacizumab in patients with relapsed/refractory and unresectable malignant peritoneal mesothelioma. J Clin Oncol 2020;38:9013-9013.
  46. Grill J, Massimino M, Bouffet E, et al. Phase II, Open-Label, Randomized, Multicenter Trial (HERBY) of Bevacizumab in Pediatric Patients With Newly Diagnosed High-Grade Glioma. J Clin Oncol 2018 Apr 1;36(10):951-958. Doi: 10.1200/JCO.2017.76.0611. Epub 2018 Feb 7.
  47. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Colon Cancer Version 3.2023. National Comprehensive Cancer Network, 2023. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Guidelines, go online to NCCN.org. Accessed November 2023.
  48. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Rectal Cancer Version 5.2023. National Comprehensive Cancer Network, 2023. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Guidelines, go online to NCCN.org. Accessed November 2023.
  49. Frumovitz M, Munsell MF, Burzawa JK, et al. Combination therapy with topotecan, paclitaxel, and bevacizumab improves progression-free survival in recurrent small cell neuroendocrine carcinoma of the cervix. Gynecol Oncol. 2017 Jan;144(1):46-50. Doi: 10.1016/j.ygyno.2016.10.040. Epub 2016 Nov 4. PMID: 27823771; PMCID: PMC5873577.
  50. Prager GW, Taieb J, Fakih M, et al.; SUNLIGHT Investigators. Trifluridine-Tipiracil and Bevacizumab in Refractory Metastatic Colorectal Cancer. N Engl J Med. 2023 May 4;388(18):1657-1667. Doi: 10.1056/NEJMoa2214963. PMID: 37133585.
  51. Bearz A, Talamini R, Rossoni G, et al. Re-challenge with pemetrexed in advanced mesothelioma: a multi-institutional experience. BMC Res Notes 2012;5:482
  1. Nagao S, Kogiku A, Suzuki K, et al. A phase II study of the combination chemotherapy of bevacizumab and gemcitabine in women with platinum-resistant recurrent epithelial ovarian, primary peritoneal, or fallopian tube cancer. J Ovarian Res 2020;13:14
  2. National Government Services, Inc. Local Coverage Article: Billing and Coding: Bevacizumab and biosimilars (A52370). Centers for Medicare & Medicaid Services, Inc. Updated on 06/21/2023 with effective date 07/01/2023. Accessed November 2023.

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

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

C18.4

Malignant neoplasm of transverse colon

C18.5

Malignant neoplasm of splenic flexure

C18.6

Malignant neoplasm of descending colon

C18.7

Malignant neoplasm of sigmoid colon

C18.8

Malignant neoplasm of overlapping sites of large intestines

C18.9

Malignant neoplasm of colon, unspecified

C19

Malignant neoplasm of rectosigmoid junction

C20

Malignant neoplasm of rectum

C21.8

Malignant neoplasm of overlapping sites of rectum, anus and anal canal

C22.0

Liver cell carcinoma

C22.3

Angiosarcoma of the liver

C22.8

Malignant neoplasm of liver, primary, unspecified as to type

C22.9

Malignant neoplasm of liver, not specified as primary or secondary

C24.1

Malignant neoplasm of ampulla of Vater

C33

Malignant neoplasm of trachea

C34.00

Malignant neoplasm of unspecified main bronchus

C34.01

Malignant neoplasm of right main bronchus

C34.02

Malignant neoplasm of left main bronchus

C34.10

Malignant neoplasm of upper lobe, unspecified bronchus or lung

C34.11

Malignant neoplasm of upper lobe, right bronchus or lung

C34.12

Malignant neoplasm of upper lobe, left bronchus or lung

C34.2

Malignant neoplasm of middle lobe, bronchus or lung

C34.30

Malignant neoplasm of lower lobe, unspecified bronchus or lung

C34.31

Malignant neoplasm of lower lobe, right bronchus or lung

C34.32

Malignant neoplasm of lower lobe, left bronchus or lung

C34.80

Malignant neoplasm of overlapping sites of unspecified bronchus or lung

C34.81

Malignant neoplasm of overlapping sites of right bronchus and lung

C34.82

Malignant neoplasm of overlapping sites of left bronchus and lung

C34.90

Malignant neoplasm of unspecified part of unspecified bronchus or lung

C34.91

Malignant neoplasm of unspecified part of right bronchus or lung

C34.92

Malignant neoplasm of unspecified part of left bronchus or lung

C45.0

Mesothelioma of pleura

C45.1

Mesothelioma of peritoneum

C45.2

Mesothelioma of pericardium

C45.7

Mesothelioma of other sites

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

C49.21

Malignant neoplasm of connective and soft tissue of right lower limb, including hip

C49.22

Malignant neoplasm of connective and soft tissue of left lower limb, including hip

C49.3

Malignant neoplasm of connective and soft tissue of thorax

C49.4

Malignant neoplasm of connective and soft tissue of abdomen

C49.5

Malignant neoplasm of connective and soft tissue of pelvis

C49.6

Malignant neoplasm of connective and soft tissue of trunk, unspecified

C49.8

Malignant neoplasm of overlapping sites of connective and soft tissue

C49.9

Malignant neoplasm of connective and soft tissue, unspecified

C51.0

Malignant neoplasm of labium majus

C51.1

Malignant neoplasm of labium minus

C51.2

Malignant neoplasm of clitoris

C51.8

Malignant neoplasm of overlapping sites of vulva

C51.9

Malignant neoplasm of vulva, unspecified

C53.0

Malignant neoplasm of endocervix

C53.1

Malignant neoplasm of exocervix

C53.8

Malignant neoplasm of overlapping sites of cervix uteri

C53.9

Malignant neoplasm of cervix uteri, unspecified

C54.0

Malignant neoplasm of isthmus uteri

C54.1

Malignant neoplasm of endometrium

C54.2

Malignant neoplasm of myometrium

C54.3

Malignant neoplasm of fundus uteri

C54.8

Malignant neoplasm of overlapping sites of corpus uteri

C54.9

Malignant neoplasm of corpus uteri, unspecified

C55

Malignant neoplasm of uterus, part unspecified

C56.1

Malignant neoplasm of right ovary

C56.2

Malignant neoplasm of left ovary

C56.3

Malignant neoplasm of bilateral ovaries

C56.9

Malignant neoplasm of unspecified ovary

C57.00

Malignant neoplasm of unspecified fallopian tube

C57.01

Malignant neoplasm of right fallopian tube

C57.02

Malignant neoplasm of left fallopian tube

C57.10

Malignant neoplasm of unspecified broad ligament

C57.11

Malignant neoplasm of right broad ligament

C57.12

Malignant neoplasm of left broad ligament

C57.20

Malignant neoplasm of unspecified round ligament

C57.21

Malignant neoplasm of right round ligament

C57.22

Malignant neoplasm of left round ligament

C57.3

Malignant neoplasm of parametrium

C57.4

Malignant neoplasm of uterine adnexa, unspecified

C57.7

Malignant neoplasm of other specified female genital organs

C57.8

Malignant neoplasm of overlapping sites of female genital organs

C57.9

Malignant neoplasm of female genital organ, unspecified

C64.1

Malignant neoplasm of right kidney, except renal pelvis

C64.2

Malignant neoplasm of left kidney, except renal pelvis

C64.9

Malignant neoplasm of unspecified kidney, except renal pelvis

C65.1

Malignant neoplasm of right renal pelvis

C65.2

Malignant neoplasm of left renal pelvis

C65.9

Malignant neoplasm of unspecified renal pelvis

C70.0

Malignant neoplasm of cerebral meninges

C70.1

Malignant neoplasm of spinal meninges

C70.9

Malignant neoplasm of meninges, unspecified

C71.0

Malignant neoplasm of cerebrum, except lobes and ventricles

C71.1

Malignant neoplasm of frontal lobe

C71.2

Malignant neoplasm of temporal lobe

C71.3

Malignant neoplasm of parietal lobe

C71.4

Malignant neoplasm of occipital lobe

C71.5

Malignant neoplasm of cerebral ventricle

C71.6

Malignant neoplasm of cerebellum

C71.7

Malignant neoplasm of brain stem

C71.8

Malignant neoplasm of overlapping sites of brain

C71.9

Malignant neoplasm of brain, unspecified

C72.0

Malignant neoplasm of spinal cord

C72.1

Malignant neoplasm of cauda equina

C72.9

Malignant neoplasm of central nervous system, unspecified

C78.00

Secondary malignant neoplasm of unspecified lung

C78.01

Secondary malignant neoplasm of right lung

C78.02

Secondary malignant neoplasm of left lung

C78.6

Secondary malignant neoplasm of retroperitoneum and peritoneum

C78.7

Secondary malignant neoplasm of liver and intrahepatic bile duct

C79.31

Secondary malignant neoplasm of brain

C83.30

Diffuse large B-cell lymphoma unspecified site

C83.39

Diffuse large B-cell lymphoma extranodal and solid organ sites

C83.80

Other non-follicular lymphoma unspecified site

C83.89

Other non-follicular lymphoma extranodal and solid organ sites

C85.89

Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites

C85.99

Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites

D19.1

Benign neoplasm of mesothelial tissue of peritoneum

D32.0

Benign neoplasm of cerebral meninges

D32.1

Benign neoplasm of spinal meninges

D32.9

Benign neoplasm of meninges, unspecified

D42.0

Neoplasm of uncertain behavior of cerebral meninges

D42.1

Neoplasm of uncertain behavior of spinal meninges

D42.9

Neoplasm of uncertain behavior of meninges, unspecified

D43.0

Neoplasm of uncertain behavior of brain, supratentorial

D43.1

Neoplasm of uncertain behavior of brain, infratentorial

D43.2

Neoplasm of uncertain behavior of brain, unspecified

D43.4

Neoplasm of uncertain behavior of spinal cord

D43.9

Neoplasm of uncertain behavior of central nervous system, unspecified

D48.1

Neoplasm of uncertain behavior of connective and other soft tissue

G93.6

Cerebral edema

I67.89

Other cerebrovascular disease

I67.9

Cerebrovascular disease, unspecified

Y84.2

Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure

Z85.038

Personal history of other malignant neoplasm of large intestine

Z85.068

Personal history of other malignant neoplasm of small intestine

Z85.09

Personal history of malignant neoplasm of other digestive organs

Z85.118

Personal history of other malignant neoplasm of bronchus and lung

Z85.42

Personal history of malignant neoplasm of other parts of uterus

Z85.43

Personal history of malignant neoplasm of ovary

Z85.831

Personal history of malignant neoplasm of soft tissue

Z85.841

Personal history of malignant neoplasm of brain

Z85.848

Personal history of malignant neoplasm of other parts of nervous tissue

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) may exist and compliance with these policies is required where applicable. They can be found at: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications may be covered at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA):

Jurisdiction(s): 6, K

NCD/LCD Document (s): A52370

https://www.cms.gov/medicare-coverage-database/new-search/search-results.aspx?keyword=a52370&areaId=all&docType=NCA%2CCAL%2CNCD%2CMEDCAC%2CTA%2CMCD%2C6%2C3%2C5%2C1%2CF%2CP

Medicare Part B Administrative Contractor (MAC) Jurisdictions

Jurisdiction

Applicable State/US Territory

Contractor

E (1)

CA, HI, NV, AS, GU, CNMI

Noridian Healthcare Solutions, LLC

F (2 & 3)

AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ

Noridian Healthcare Solutions, LLC

5

KS, NE, IA, MO

Wisconsin Physicians Service Insurance Corp (WPS)

6

MN, WI, IL

National Government Services, Inc. (NGS)

H (4 & 7)

LA, AR, MS, TX, OK, CO, NM

Novitas Solutions, Inc.

8

MI, IN

Wisconsin Physicians Service Insurance Corp (WPS)

N (9)

FL, PR, VI

First Coast Service Options, Inc.

J (10)

TN, GA, AL

Palmetto GBA, LLC

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA, LLC

L (12)

DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA)

Novitas Solutions, Inc.

K (13 & 14)

NY, CT, MA, RI, VT, ME, NH

National Government Services, Inc. (NGS)

15

KY, OH

CGS Administrators, LLC

 

 

 

 

BEVACIZUMAB

(AVASTIN®; MVASI®; ZIRABEV™; ALYMSYS®; VEGZELMA®)

Prior Auth Criteria - Oncology
Proprietary Information. Restricted Access – Do not disseminate or copy without approval.
©2023, Magellan Rx Management

White MRx.PNG