Some agents on this policy may require step therapy See “Step Therapy Requirements for Provider Administered Specialty Medications” Document at: https://www.bcbst.com/docs/providers/Comm_BC_PAD_Step_Therapy_Guide.pdf

IMPORTANT REMINDER

We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the medical policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.

POLICY

The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.

FDA-Approved Indications

Metastatic Colorectal Cancer (mCRC)

Avastin, Alymsys, Avzivi, Jobevne, Mvasi, Vegzelma or Zirabev, in combination with intravenous fluorouracil-based chemotherapy, is indicated for the first- or second-line treatment of patients with metastatic colorectal cancer.
Avastin, Alymsys, Avzivi, Jobevne, Mvasi, Vegzelma or Zirabev, in combination with fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy, is indicated for the second-line treatment of patients with metastatic colorectal cancer who have progressed on a first-line bevacizumab product-containing regimen.

First-Line Non-Squamous Non-Small Cell Lung Cancer (NSCLC)

Avastin, Alymsys, Avzivi, Jobevne, Mvasi, Vegzelma or Zirabev, in combination with carboplatin and paclitaxel, is indicated for the first-line treatment of patients with unresectable, locally advanced, recurrent or metastatic non–squamous non–small cell lung cancer.

Recurrent Glioblastoma (RGM)

Avastin, Alymsys, Avzivi, Jobevne, Mvasi, Vegzelma or Zirabev, is indicated for the treatment of recurrent glioblastoma in adults.

Metastatic Renal Cell Carcinoma (mRCC)

Avastin, Alymsys, Avzivi, Mvasi, Vegzelma or Zirabev, in combination with interferon alfa, is indicated for the treatment of metastatic renal cell carcinoma.

Persistent, Recurrent, or Metastatic Cervical Cancer

Avastin, Alymsys, Avzivi, Jobevne, Mvasi, Vegzelma or Zirabev, in combination with paclitaxel and cisplatin or paclitaxel and topotecan, is indicated for the treatment of patients with persistent, recurrent, or metastatic cervical cancer.

Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer

Avastin, Jobevne, Mvasi, Vegzelma or Zirabev, in combination with carboplatin and paclitaxel, followed by Avastin, Jobevne, Mvasi, Vegzelma or Zirabev as a single agent, is indicated for the treatment of patients with stage III or IV epithelial ovarian, fallopian tube, or primary peritoneal cancer following initial surgical resection.
Avastin, Alymsys, Avzivi, Jobevne, Mvasi, Vegzelma or Zirabev, in combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan, is indicated for the treatment of patients with platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer who received no more than 2 prior chemotherapy regimens.
Avastin, Jobevne, Mvasi, Vegzelma or Zirabev, in combination with carboplatin and paclitaxel, or with carboplatin and gemcitabine, followed by Avastin, Jobevne, Mvasi, Vegzelma or Zirabev as a single agent, is indicated for the treatment of patients with platinum-sensitive recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer.

Hepatocellular Carcinoma

Avastin, in combination with atezolizumab, is indicated for the treatment of patients with unresectable or metastatic hepatocellular carcinoma (HCC) who have not received prior systemic therapy.

Compendial Uses

Central Nervous System (CNS) Cancers

Circumscribed glioma
Diffuse high grade and high grade gliomas
Glioblastoma
IDH mutant astrocytoma (WHO Grade 2, 3, or 4)
Oligodendroglioma (WHO Grade 2 or 3)
Intracranial and Spinal Ependymoma (excluding subependymoma)
Medulloblastoma
Primary Central Nervous System Lymphoma
Meningiomas
Limited and Extensive Brain Metastases
Metastatic Spine Tumors
Primary Spinal Cord Tumors

Pleural Mesothelioma, Peritoneal Mesothelioma, Pericardial Mesothelioma, Tunica Vaginalis Testis Mesothelioma
Ovarian Cancer, Fallopian Tube Cancer, Primary Peritoneal Cancer
Soft Tissue Sarcoma

Angiosarcoma
Solitary Fibrous Tumor/Hemangiopericytoma

Uterine Neoplasms/Endometrial Carcinoma
Vulvar Carcinoma
Vaginal Cancer
Cervical Cancer
Small Bowel Adenocarcinoma
Ampullary Adenocarcinoma
Appendiceal Adenocarcinoma
Anal Adenocarcinoma
Renal Cell Carcinoma
Hepatocellular Carcinoma
Ophthalmic Disorders

Diabetic Macular Edema
Neovascular (wet) Age-Related Macular Degeneration
Macular Edema following Retinal Vein Occlusion
Proliferative Diabetic Retinopathy
Choroidal Neovascularization
Neovascular Glaucoma
Retinopathy of Prematurity
Polypoidal Choroidal Vasculopathy

All other indications are considered experimental/investigational and not medically necessary.

COVERAGE CRITERIA

Ophthalmic Disorders

Authorization of 6 months may be granted for treatment of the following retinal disorders:

Diabetic Macular Edema
Neovascular (wet) Age-Related Macular Degeneration
Macular Edema following Retinal Vein Occlusion
Proliferative Diabetic Retinopathy
Choroidal Neovascularization (including myopic choroidal neovascularization, angioid streaks, choroiditis [including choroiditis secondary to ocular histoplasmosis], idiopathic degenerative myopia, retinal dystrophies, rubeosis iridis, pseudoxanthoma elasticum, and trauma)
Neovascular Glaucoma
Retinopathy of Prematurity
Polypoidal Choroidal Vasculopathy

Colorectal Cancer (CRC)

Authorization of 12 months may be granted for treatment of colorectal cancer, including appendiceal adenocarcinoma and anal adenocarcinoma.

Small Bowel Adenocarcinoma

Authorization of 12 months may be granted for treatment of small bowel adenocarcinoma.

Ampullary Adenocarcinoma

Authorization of 12 months may be granted for treatment of intestinal-type ampullary adenocarcinoma that is progressive, unresectable, or metastatic.

Non-Small Cell Lung Cancer (NSCLC)

Authorization of 12 months may be granted for treatment of recurrent, unresectable, advanced, or metastatic non-squamous NSCLC.

CNS Cancer

Authorization of 12 months may be granted for treatment of the following types of CNS cancer:

Circumscribed glioma
Diffuse high grade and high grade gliomas
Glioblastoma
IDH mutant astrocytoma (WHO Grade 2, 3 or 4)
Oligodendroglioma (WHO Grade 2 or 3)
Intracranial and Spinal Ependymoma (excludes subependymoma)
Medulloblastoma
Primary Central Nervous System Lymphoma
Meningiomas
Limited and Extensive Brain Metastases
Metastatic Spine Tumors
Primary Spinal Cord Tumors

Ovarian Cancer/Fallopian Tube Cancer/Primary Peritoneal Cancer

Authorization of 12 months may be granted for treatment of epithelial ovarian cancer, fallopian tube cancer, primary peritoneal cancer, and malignant sex cord stromal tumors.

Uterine Neoplasms/Endometrial Carcinoma

Authorization of 12 months may be granted for treatment of progressive, persistent, recurrent, or metastatic uterine neoplasms or endometrial carcinoma.

Cervical Cancer

Authorization of 12 months may be granted for treatment of persistent, recurrent, or metastatic cervical cancer.

Vaginal Cancer

Authorization of 12 months may be granted for treatment of recurrent or metastatic vaginal cancer.

Renal Cell Carcinoma

Authorization of 12 months may be granted for treatment of relapsed or stage IV renal cell carcinoma.

Soft Tissue Sarcoma

Authorization of 12 months may be granted for treatment of angiosarcoma, as single agent therapy.

Authorization of 12 months may be granted for treatment of solitary fibrous tumor or hemangiopericytoma, in combination with temozolomide.

Mesothelioma

Authorization of 12 months may be granted for treatment of pleural mesothelioma, peritoneal mesothelioma, pericardial mesothelioma, or tunica vaginalis testis mesothelioma when any of the following criteria are met:

As first-line therapy in combination with pemetrexed and either cisplatin or carboplatin, followed by single-agent maintenance bevacizumab
As subsequent therapy in combination with pemetrexed and either cisplatin or carboplatin if immunotherapy was administered as first-line treatment

Authorization of 12 months may be granted for treatment of peritoneal mesothelioma, pericardial mesothelioma, or tunica vaginalis testis mesothelioma when used in combination with atezolizumab as subsequent therapy.

Vulvar Carcinoma

Authorization of 12 months may be granted for treatment of advanced, recurrent, or metastatic vulvar carcinoma, including squamous cell carcinoma and adenocarcinoma.

Hepatocellular Carcinoma

Authorization of 12 months may be granted for treatment of unresectable or extrahepatic/ metastatic hepatocellular carcinoma, when the requested medication will be used as initial treatment in combination with atezolizumab.

Authorization of 12 months may be granted for adjuvant treatment of operable hepatocellular carcinoma, when the member is at a high risk of recurrence and the requested medication will be used in combination with atezolizumab.

CONTINUATION OF THERAPY

Ophthalmic Disorders

For ophthalmic disorders, authorization of 12 months may be granted for continued treatment in members requesting reauthorization for an indication listed in coverage criteria section when the member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in best corrected visual acuity [BCVA] or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).

All Other Indications

For all other indications, authorization of 12 months may be granted for continued treatment in members requesting reauthorization for an indication listed in coverage criteria section when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

MEDICATION QUANTITY LIMITS

Drug Name	Diagnosis	Maximum Dosing Regimen
Alymsys (Bevacizumab-maly)	Ampullary Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Alymsys (Bevacizumab-maly)	Cervical Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Alymsys (Bevacizumab-maly)	CNS Cancer, including Glioblastoma	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Alymsys (Bevacizumab-maly)	Colorectal Cancer, including Appendiceal Adenocarcinoma and Anal Adenocarcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Alymsys (Bevacizumab-maly)	Diabetic Macular Edema	Route of Administration: Intravitreal ≥18 year(s) 1.5mg in the affected eye(s) every 4 weeks
Alymsys (Bevacizumab-maly)	Hepatocellular Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Alymsys (Bevacizumab-maly)	Macular Edema following Retinal Vein Occlusion	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) once and repeat at 1 to 3 month intervals
Alymsys (Bevacizumab-maly)	Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Pericardial Mesothelioma, or Tunica Vaginalis Testis Mesothelioma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Alymsys (Bevacizumab-maly)	Neovascular (wet) Age-Related Macular Degeneration (AMD), Choroidal Neovascularization	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks 2.5mg in the affected eye(s) every 4 weeks for 3 doses
Alymsys (Bevacizumab-maly)	Neovascular Glaucoma (Adjunct)	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Alymsys (Bevacizumab-maly)	Non-Small Cell Lung Cancer (NSCLC)	Route of Administration: Intravenous 15mg/kg every 3 weeks
Alymsys (Bevacizumab-maly)	Ovarian, Fallopian, Primary Peritoneal Cancer	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Alymsys (Bevacizumab-maly)	Polypoidal Choroidal Vasculopathy	Route of Administration: Intravitreal 2.5mg in the affected eye(s); frequency should not be more frequent than every 4 weeks
Alymsys (Bevacizumab-maly)	Proliferative Diabetic Retinopathy	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Alymsys (Bevacizumab-maly)	Renal Cell Carcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Alymsys (Bevacizumab-maly)	Retinopathy of Prematurity	Route of Administration: Intravitreal <18 year(s) 0.625mg in the affected eye(s) for 1 dose
Alymsys (Bevacizumab-maly)	Small Bowel Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Alymsys (Bevacizumab-maly)	Soft Tissue Sarcoma: Angiosarcoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Alymsys (Bevacizumab-maly)	Soft Tissue Sarcoma: Solitary Fibrous Tumor	Route of Administration: Intravenous 5mg/kg every 2 weeks
Alymsys (Bevacizumab-maly)	Uterine Neoplasms - Endometrial Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Alymsys (Bevacizumab-maly)	Vaginal Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Alymsys (Bevacizumab-maly)	Vulvar Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avastin (Bevacizumab)	Ampullary Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Avastin (Bevacizumab)	Cervical Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avastin (Bevacizumab)	CNS Cancer, including Glioblastoma	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Avastin (Bevacizumab)	Colorectal Cancer, including Appendiceal Adenocarcinoma and Anal Adenocarcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Avastin (Bevacizumab)	Diabetic Macular Edema	Route of Administration: Intravitreal ≥18 year(s) 1.5mg in the affected eye(s) every 4 weeks
Avastin (Bevacizumab)	Hepatocellular Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avastin (Bevacizumab)	Macular Edema following Retinal Vein Occlusion	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) once and repeat at 1 to 3 month intervals
Avastin (Bevacizumab)	Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Pericardial Mesothelioma, or Tunica Vaginalis Testis Mesothelioma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avastin (Bevacizumab)	Neovascular (wet) Age-Related Macular Degeneration (AMD), Choroidal Neovascularization	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks 2.5mg in the affected eye(s) every 4 weeks for 3 doses
Avastin (Bevacizumab)	Neovascular Glaucoma (Adjunct)	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Avastin (Bevacizumab)	Non-Small Cell Lung Cancer (NSCLC)	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avastin (Bevacizumab)	Ovarian, Fallopian, Primary Peritoneal Cancer	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Avastin (Bevacizumab)	Polypoidal Choroidal Vasculopathy	Route of Administration: Intravitreal 2.5mg in the affected eye(s); frequency should not be more frequent than every 4 weeks
Avastin (Bevacizumab)	Proliferative Diabetic Retinopathy	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Avastin (Bevacizumab)	Renal Cell Carcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Avastin (Bevacizumab)	Retinopathy of Prematurity	Route of Administration: Intravitreal <18year(s) 0.625mg in the affected eye(s) for 1 dose
Avastin (Bevacizumab)	Small Bowel Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Avastin (Bevacizumab)	Soft Tissue Sarcoma: Angiosarcoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avastin (Bevacizumab)	Soft Tissue Sarcoma: Solitary Fibrous Tumor	Route of Administration: Intravenous 5mg/kg every 2 weeks
Avastin (Bevacizumab)	Uterine Neoplasms - Endometrial Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avastin (Bevacizumab)	Vaginal Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avastin (Bevacizumab)	Vulvar Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avzivi (Bevacizumab-tnjn)	Ampullary Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Avzivi (Bevacizumab-tnjn)	Cervical Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avzivi (Bevacizumab-tnjn)	CNS Cancer, including Glioblastoma	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Avzivi (Bevacizumab-tnjn)	Colorectal Cancer, including Appendiceal Adenocarcinoma and Anal Adenocarcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Avzivi (Bevacizumab-tnjn)	Diabetic Macular Edema	Route of Administration: Intravitreal ≥18 year(s) 1.5mg in the affected eye(s) every 4 weeks
Avzivi (Bevacizumab-tnjn)	Hepatocellular Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avzivi (Bevacizumab-tnjn)	Macular Edema following Retinal Vein Occlusion	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) once and repeat at 1 to 3 month intervals
Avzivi (Bevacizumab-tnjn)	Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Pericardial Mesothelioma, or Tunica Vaginalis Testis Mesothelioma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avzivi (Bevacizumab-tnjn)	Neovascular (wet) Age-Related Macular Degeneration (AMD), Choroidal Neovascularization	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks 2.5mg in the affected eye(s) every 4 weeks for 3 doses
Avzivi (Bevacizumab-tnjn)	Neovascular Glaucoma (Adjunct)	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Avzivi (Bevacizumab-tnjn)	Non-Small Cell Lung Cancer (NSCLC)	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avzivi (Bevacizumab-tnjn)	Ovarian, Fallopian, Primary Peritoneal Cancer	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Avzivi (Bevacizumab-tnjn)	Polypoidal Choroidal Vasculopathy	Route of Administration: Intravitreal 2.5mg in the affected eye(s); frequency should not be more frequent than every 4 weeks
Avzivi (Bevacizumab-tnjn)	Proliferative Diabetic Retinopathy	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Avzivi (Bevacizumab-tnjn)	Renal Cell Carcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Avzivi (Bevacizumab-tnjn)	Retinopathy of Prematurity	Route of Administration: Intravitreal <18 year(s) 0.625mg in the affected eye(s) for 1 dose
Avzivi (Bevacizumab-tnjn)	Small Bowel Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Avzivi (Bevacizumab-tnjn)	Soft Tissue Sarcoma: Angiosarcoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avzivi (Bevacizumab-tnjn)	Soft Tissue Sarcoma: Solitary Fibrous Tumor	Route of Administration: Intravenous 5mg/kg every 2 weeks
Avzivi (Bevacizumab-tnjn)	Uterine Neoplasms - Endometrial Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avzivi (Bevacizumab-tnjn)	Vaginal Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Avzivi (Bevacizumab-tnjn)	Vulvar Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Jobevne (Bevacizumab-nwgd)	Ampullary Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Jobevne (Bevacizumab-nwgd)	Cervical Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Jobevne (Bevacizumab-nwgd)	CNS Cancer, including Glioblastoma	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Jobevne (Bevacizumab-nwgd)	Colorectal Cancer, including Appendiceal Adenocarcinoma and Anal Adenocarcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Jobevne (Bevacizumab-nwgd)	Diabetic Macular Edema	Route of Administration: Intravitreal ≥18 year(s) 1.5mg in the affected eye(s) every 4 weeks
Jobevne (Bevacizumab-nwgd)	Hepatocellular Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Jobevne (Bevacizumab-nwgd)	Macular Edema following Retinal Vein Occlusion	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) once and repeat at 1 to 3 month intervals
Jobevne (Bevacizumab-nwgd)	Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Pericardial Mesothelioma, or Tunica Vaginalis Testis Mesothelioma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Jobevne (Bevacizumab-nwgd)	Neovascular (wet) Age-Related Macular Degeneration (AMD), Choroidal Neovascularization	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks 2.5mg in the affected eye(s) every 4 weeks for 3 doses
Jobevne (Bevacizumab-nwgd)	Neovascular Glaucoma (Adjunct)	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Jobevne (Bevacizumab-nwgd)	Non-Small Cell Lung Cancer (NSCLC)	Route of Administration: Intravenous 15mg/kg every 3 weeks
Jobevne (Bevacizumab-nwgd)	Ovarian, Fallopian, Primary Peritoneal Cancer	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Jobevne (Bevacizumab-nwgd)	Polypoidal Choroidal Vasculopathy	Route of Administration: Intravitreal 2.5mg in the affected eye(s); frequency should not be more frequent than every 4 weeks
Jobevne (Bevacizumab-nwgd)	Proliferative Diabetic Retinopathy	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Jobevne (Bevacizumab-nwgd)	Renal Cell Carcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Jobevne (Bevacizumab-nwgd)	Retinopathy of Prematurity	Route of Administration: Intravitreal <18year(s) 0.625mg in the affected eye(s) for 1 dose
Jobevne (Bevacizumab-nwgd)	Small Bowel Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Jobevne (Bevacizumab-nwgd)	Soft Tissue Sarcoma: Angiosarcoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Jobevne (Bevacizumab-nwgd)	Soft Tissue Sarcoma: Solitary Fibrous Tumor	Route of Administration: Intravenous 5mg/kg every 2 weeks
Jobevne (Bevacizumab-nwgd)	Uterine Neoplasms - Endometrial Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Jobevne (Bevacizumab-nwgd)	Vaginal Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Jobevne (Bevacizumab-nwgd)	Vulvar Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Mvasi (Bevacizumab-awwb)	Ampullary Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Mvasi (Bevacizumab-awwb)	Cervical Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Mvasi (Bevacizumab-awwb)	CNS Cancer, including Glioblastoma	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Mvasi (Bevacizumab-awwb)	Colorectal Cancer, including Appendiceal Adenocarcinoma and Anal Adenocarcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Mvasi (Bevacizumab-awwb)	Diabetic Macular Edema	Route of Administration: Intravitreal ≥18 year(s) 1.5mg in the affected eye(s) every 4 weeks
Mvasi (Bevacizumab-awwb)	Hepatocellular Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Mvasi (Bevacizumab-awwb)	Macular Edema following Retinal Vein Occlusion	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) once and repeat at 1 to 3 month intervals
Mvasi (Bevacizumab-awwb)	Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Pericardial Mesothelioma, or Tunica Vaginalis Testis Mesothelioma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Mvasi (Bevacizumab-awwb)	Neovascular (wet) Age-Related Macular Degeneration (AMD), Choroidal Neovascularization	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks 2.5mg in the affected eye(s) every 4 weeks for 3 doses
Mvasi (Bevacizumab-awwb)	Neovascular Glaucoma (Adjunct)	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Mvasi (Bevacizumab-awwb)	Non-Small Cell Lung Cancer (NSCLC)	Route of Administration: Intravenous 15mg/kg every 3 weeks
Mvasi (Bevacizumab-awwb)	Ovarian, Fallopian, Primary Peritoneal Cancer	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Mvasi (Bevacizumab-awwb)	Polypoidal Choroidal Vasculopathy	Route of Administration: Intravitreal 2.5mg in the affected eye(s); frequency should not be more frequent than every 4 weeks
Mvasi (Bevacizumab-awwb)	Proliferative Diabetic Retinopathy	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Mvasi (Bevacizumab-awwb)	Renal Cell Carcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Mvasi (Bevacizumab-awwb)	Retinopathy of Prematurity	Route of Administration: Intravitreal <18year(s) 0.625mg in the affected eye(s) for 1 dose
Mvasi (Bevacizumab-awwb)	Small Bowel Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Mvasi (Bevacizumab-awwb)	Soft Tissue Sarcoma: Angiosarcoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Mvasi (Bevacizumab-awwb)	Soft Tissue Sarcoma: Solitary Fibrous Tumor	Route of Administration: Intravenous 5mg/kg every 2 weeks
Mvasi (Bevacizumab-awwb)	Uterine Neoplasms - Endometrial Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Mvasi (Bevacizumab-awwb)	Vaginal Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Mvasi (Bevacizumab-awwb)	Vulvar Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Vegzelma (Bevacizumab-adcd)	Ampullary Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Vegzelma (Bevacizumab-adcd)	Cervical Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Vegzelma (Bevacizumab-adcd)	CNS Cancer, including Glioblastoma	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Vegzelma (Bevacizumab-adcd)	Colorectal Cancer, including Appendiceal Adenocarcinoma and Anal Adenocarcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Vegzelma (Bevacizumab-adcd)	Diabetic Macular Edema	Route of Administration: Intravitreal ≥18 year(s) 1.5mg in the affected eye(s) every 4 weeks
Vegzelma (Bevacizumab-adcd)	Hepatocellular Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Vegzelma (Bevacizumab-adcd)	Macular Edema following Retinal Vein Occlusion	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) once and repeat at 1 to 3 month intervals
Vegzelma (Bevacizumab-adcd)	Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Pericardial Mesothelioma, or Tunica Vaginalis Testis Mesothelioma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Vegzelma (Bevacizumab-adcd)	Neovascular (wet) Age-Related Macular Degeneration (AMD), Choroidal Neovascularization	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks 2.5mg in the affected eye(s) every 4 weeks for 3 doses
Vegzelma (Bevacizumab-adcd)	Neovascular Glaucoma (Adjunct)	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Vegzelma (Bevacizumab-adcd)	Non-Small Cell Lung Cancer (NSCLC)	Route of Administration: Intravenous 15mg/kg every 3 weeks
Vegzelma (Bevacizumab-adcd)	Ovarian, Fallopian, Primary Peritoneal Cancer	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Vegzelma (Bevacizumab-adcd)	Polypoidal Choroidal Vasculopathy	Route of Administration: Intravitreal 2.5mg in the affected eye(s); frequency should not be more frequent than every 4 weeks
Vegzelma (Bevacizumab-adcd)	Proliferative Diabetic Retinopathy	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Vegzelma (Bevacizumab-adcd)	Renal Cell Carcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Vegzelma (Bevacizumab-adcd)	Retinopathy of Prematurity	Route of Administration: Intravitreal <18year(s) 0.625mg in the affected eye(s) for 1 dose
Vegzelma (Bevacizumab-adcd)	Small Bowel Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Vegzelma (Bevacizumab-adcd)	Soft Tissue Sarcoma: Angiosarcoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Vegzelma (Bevacizumab-adcd)	Soft Tissue Sarcoma: Solitary Fibrous Tumor	Route of Administration: Intravenous 5mg/kg every 2 weeks
Vegzelma (Bevacizumab-adcd)	Uterine Neoplasms - Endometrial Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Vegzelma (Bevacizumab-adcd)	Vaginal Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Vegzelma (Bevacizumab-adcd)	Vulvar Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Zirabev (Bevacizumab-bvzr)	Ampullary Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Zirabev (Bevacizumab-bvzr)	Cervical Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Zirabev (Bevacizumab-bvzr)	CNS Cancer, including Glioblastoma	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Zirabev (Bevacizumab-bvzr)	Colorectal Cancer, including Appendiceal Adenocarcinoma and Anal Adenocarcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Zirabev (Bevacizumab-bvzr)	Diabetic Macular Edema	Route of Administration: Intravitreal ≥18 year(s) 1.5mg in the affected eye(s) every 4 weeks
Zirabev (Bevacizumab-bvzr)	Hepatocellular Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Zirabev (Bevacizumab-bvzr)	Macular Edema following Retinal Vein Occlusion	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) once and repeat at 1 to 3 month intervals
Zirabev (Bevacizumab-bvzr)	Malignant Pleural Mesothelioma, Malignant Peritoneal Mesothelioma, Pericardial Mesothelioma, or Tunica Vaginalis Testis Mesothelioma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Zirabev (Bevacizumab-bvzr)	Neovascular (wet) Age-Related Macular Degeneration (AMD), Choroidal Neovascularization	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks 2.5mg in the affected eye(s) every 4 weeks for 3 doses
Zirabev (Bevacizumab-bvzr)	Neovascular Glaucoma (Adjunct)	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Zirabev (Bevacizumab-bvzr)	Non-Small Cell Lung Cancer (NSCLC)	Route of Administration: Intravenous 15mg/kg every 3 weeks
Zirabev (Bevacizumab-bvzr)	Ovarian, Fallopian, Primary Peritoneal Cancer	Route of Administration: Intravenous 10mg/kg every 2 weeks 15mg/kg every 3 weeks
Zirabev (Bevacizumab-bvzr)	Polypoidal Choroidal Vasculopathy	Route of Administration: Intravitreal 2.5mg in the affected eye(s); frequency should not be more frequent than every 4 weeks
Zirabev (Bevacizumab-bvzr)	Proliferative Diabetic Retinopathy	Route of Administration: Intravitreal ≥18 year(s) 1.25mg in the affected eye(s) every 4 weeks
Zirabev (Bevacizumab-bvzr)	Renal Cell Carcinoma	Route of Administration: Intravenous 10mg/kg every 2 weeks
Zirabev (Bevacizumab-bvzr)	Retinopathy of Prematurity	Route of Administration: Intravitreal <18year(s) 0.625mg in the affected eye(s) for 1 dose
Zirabev (Bevacizumab-bvzr)	Small Bowel Adenocarcinoma	Route of Administration: Intravenous 5mg/kg every 2 weeks 7.5mg/kg every 3 weeks
Zirabev (Bevacizumab-bvzr)	Soft Tissue Sarcoma: Angiosarcoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Zirabev (Bevacizumab-bvzr)	Soft Tissue Sarcoma: Solitary Fibrous Tumor	Route of Administration: Intravenous 5mg/kg every 2 weeks
Zirabev (Bevacizumab-bvzr)	Uterine Neoplasms - Endometrial Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks
Zirabev (Bevacizumab-bvzr)	Vaginal Cancer	Route of Administration: Intravenous 15mg/kg every 3 weeks
Zirabev (Bevacizumab-bvzr)	Vulvar Carcinoma	Route of Administration: Intravenous 15mg/kg every 3 weeks

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.

ADDITIONAL INFORMATION

For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).

REFERENCES

Avastin [package insert]. South San Francisco, CA: Genentech, Inc.; September 2022.
Alymsys [package insert]. Bridgewater, NJ: Amneal Pharmaceuticals LLC; April 2022.
Avzivi [package insert]. Guangzhou, Guangdong Province, China: Bio-Thera Solutions, Ltd.; December 2023.
Mvasi [package insert]. Thousand Oaks, CA: Amgen Inc.; February 2023.
Zirabev [package insert]. New York, NY: Pfizer Inc.; August 2024.
Vegzelma [package insert]. Incheon, Republic of Korea: Celltrion, Inc.; February 2023.
The NCCN Drugs & Biologics Compendium^® © 2024 National Comprehensive Cancer Network, Inc. Available at: https://www.nccn.org. Accessed November 11, 2024.
Micromedex Solutions [database online]. Truven Health Analytics, Greenwood Village, CO. Available at: http://www.micromedexsolutions.com. Accessed February 10, 2025.
Chan WM, Lai TY, Lui DT, et al. Intravitreal bevacizumab (Avastin) for myopic choroidal neovascularization: 1-year results of a prospective pilot study. Br J Ophthalmol. 2009;93(2):150-154.
Clinical Consult: CVS Caremark Clinical Programs Review. Focus on Age-Related Macular Degeneration Clinical Programs. April 2011.
Gupta B, Elagouz M, Sivaprasad S. Intravitreal bevacizumab for choroidal neovascularization secondary to causes other than age-related macular degeneration. Eye. 2010;24:203-213.
CATT Research Group, Martin DF, Maguire MG, et al. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. N Engl J Med. 2011;364(20):1897-1908.
Russo V, Barone A, Conte E, et al. Bevacizumab compared with macular laser grid photocoagulation for cystoid macular edema in branch retinal vein occlusion. Retina. 2009;29:511-5.
Michaelides M, Kaines A, Hamilton RD, et al. A prospective randomized trial of intravitreal bevacizumab or laser therapy in the management of diabetic macular edema (BOLT Study) 12-month data: report 2. Ophthalmology. 2010;117:1078-1086.
Mirshahi A, Roohipoor R, Lashay A, et al. Bevacizumab-augmented retinal laser photocoagulation in proliferative diabetic retinopathy: a randomized double-masked clinical trial. Eur J Ophthalmol. 2008;18(2):263-269.
Yazdani S, Hendi K, Pakravan M, et al. Intravitreal bevacizumab for neovascular glaucoma: a randomized controlled trial. J Glaucoma. 2009;18(8):632-637.
Mintz-Hittner HA, Kennedy KA, Chuang AZ, et al. Efficacy of intravitreal bevacizumab for stage 3+ retinopathy of prematurity. N Engl J Med. 2011;364(7):603-615.
American Academy of Ophthalmology Retinal/Vitreous Panel. Preferred Practice Pattern^® Guidelines. Age-Related Macular Degeneration. San Francisco, CA: American Academy of Ophthalmology; 2019. Available at: https://www.aao.org/preferred-practice-pattern/age-related-macular-degeneration-ppp.
American Academy of Ophthalmology Retinal/Vitreous Panel. Preferred Practice Pattern^® Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2019. Available at: https://www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp.
American Academy of Ophthalmology Retinal/Vitreous Panel. Preferred Practice Pattern^® Guidelines. Retinal Vein Occlusions. San Francisco, CA: American Academy of Ophthalmology; 2019. Available at: https://www.aao.org/preferred-practice-pattern/retinal-vein-occlusions-ppp.
VanderVeen DK, Melia M, Yang MB, et al. Anti-vascular endothelial growth factor therapy in primary treatment of type 1 retinopathy of prematurity: a report by the American Academy of Ophthalmology. Ophthalmology. 2017. May;124(5):619-633.
AHFS DI (Adult and Pediatric) [database online]. Hudson, OH: Lexi-Comp, Inc.; http://online.lexi.com/lco/action/index/dataset/complete_ashp [available with subscription]. Accessed November 12, 2024.
Yong M, Zhou M, Deng G. Photodynamic therapy versus anti-vascular endothelial growth factor agents for polypoidal choroidal vasculopathy: A meta-analysis. BMC Ophthalmol. 2015;15:82.
Kim JH, Kim JW, Lee TG, Lew YJ. Treatment outcomes in eyes with polypoidal choroidal vasculopathy with poor baseline visual acuity. J Ocul Pharmacol Ther. 2015;31(4):241-247.
Oishi A. The evidence for the treatment of polypoidal choroidal vasculopathy. Nippon Ganka Gakkai Zasshi. 2015;119(11):781-786.
Chang YS, Kim JH, Kim KM, et al. Long-term outcomes of anti-vascular endothelial growth factor therapyfor polypoidal choroidal vasculopathy. J Ocul Pharmacol Ther. 2016;32(4):219-224.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Colon Cancer Version 5.2024. https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf. Accessed November 11, 2024.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer Version 4.2024. https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf. Accessed November 11, 2024.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Anal Carcinoma Version 1.2024. https://www.nccn.org/professionals/physician_gls/pdf/anal.pdf. Accessed November 11, 2024.
Lexicomp [database online]. Hudson, OH: Lexi-Comp, Inc.; https://online.lexi.com/lco/action/home [available with subscription]. Accessed February 19, 2025.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Soft Tissue Sarcoma Version 3.2024. https://www.nccn.org/professionals/physician_gls/pdf/sarcoma.pdf. Accessed November 19, 2024.
Jobevne [package insert]. Cambridge, MA: Biocon Biologics Inc.; April 2025.

ORIGINAL EFFECTIVE DATE: 2/1/2005

MOST RECENT REVIEW DATE: 12/31/2025

ID_CHS

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.