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AetnaCommercial · Coverage · Medical Policy · Oncology, OB-GYN, UrologyMedium impact

Avelumab (Bavencio) (CPB 0916, reviewed 2025-10-09)

Effective date
Not stated in the notice
Identified
Aug 12, 2026

Summary

Aetna's criteria cover avelumab (Bavencio) for Merkel cell carcinoma as a single agent; first-line advanced renal cell carcinoma with clear cell histology in combination with axitinib; urothelial carcinomas (bladder cancer, primary carcinoma of the urethra, upper genitourinary tract tumors, and urothelial carcinoma of the prostate) as subsequent therapy or as maintenance therapy when there is no progression on first-line platinum-containing chemotherapy; gestational trophoblastic neoplasia; recurrent endometrial carcinoma (as a single agent when MSI-H or dMMR, or with axitinib when pMMR); thymic carcinoma with axitinib; relapsed or refractory extranodal NK/T-cell lymphoma; and colorectal or small bowel adenocarcinoma that is dMMR/MSI-H or POLE/POLD1 ultra-hypermutated, as a single agent or as neoadjuvant treatment of up to 6 months. Members who have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy are not eligible, and all other indications are considered experimental, investigational or unproven. This policy addresses avelumab for commercial medical plans, where precertification is required and the Site of Care Utilization Management Policy applies.

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What to do

Action · 8 steps
01REQUIREMENTS: Billing team: Confirm precertification for avelumab (Bavencio) before the drug is given, since precertification is required of all Aetna participating providers and members in applicable plan designs.
02Precertification is requested by calling (866) 752-7021 or faxing (888) 267-3277, and Statement of Medical Necessity precertification forms are found under Specialty Pharmacy Precertification.
03Confirm the site of care meets the Utilization Management Policy on Site of Care for Specialty Drug Infusions.
04Confirm the member's indication is one of the covered indications and that the member has not experienced disease progression while on PD-1 or PD-L1 inhibitor therapy.
05Bill HCPCS J9023 (injection, avelumab, 10 mg) for covered indications when the selection criteria are met.
06Per FDA labeling, the dose is 800 mg intravenously over 60 minutes every 2 weeks for Merkel cell carcinoma and urothelial carcinoma, and 800 mg intravenously every 2 weeks with axitinib 5 mg orally twice daily for renal cell carcinoma, until disease progression or unacceptable toxicity.
07Approvals may be subject to dosing limits per FDA labeling, accepted compendia or evidence-based guidelines, so check Medical Specialty Medication Quantity Limits.
08Continuation requests must show no evidence of unacceptable toxicity or disease progression on the current regimen.

Codes mentioned

9641396417J9023J9022J9045J9060J9173J9263J9271J9299C19C20C37C55C58C61C68.0C86.00C86.01C08.0C23C76.0C80.1

Original notice

Avelumab (Bavencio) (CPB 0916, reviewed 2025-10-09)
aetna.com · Always check the source before changing claims.
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Related changes

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Related policy hubs

Aetna policiesOncologyOB-GYNUrologyCode 96413Code 96417Code J9023Code J9022Code J9045Code J9060Code J9173Code J9263Code J9271Code J9299Code C19Code C20Code C37Code C55Code C58Code C61Code C68.0Code C86.00Code C86.01Code C08.0Code C23Code C76.0Code C80.1

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