Summary
Humana has implemented a new Prior Authorization pharmacy coverage policy for bevacizumab products (Avastin, Mvasi, Zirabev, Vegzelma, Alymsys, Jobevne) effective immediately. The policy establishes specific clinical criteria and step-therapy requirements for six oncology indications and three ophthalmology indications across Medicare and three state Medicaid programs (Kentucky, South Carolina, Virginia). Billing staff must verify member eligibility against detailed criteria before processing claims for these drugs.
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What to do
Action · 7 steps
01Effective immediately (2026-10-28): Billing and prior authorization staff must implement the following for all bevacizumab product claims under Medicare, Medicaid–Kentucky, Medicaid–South Carolina, and Medicaid–Virginia plans.
02Require prior authorization for all bevacizumab HCPCS codes (J9035, Q5107, Q5118, Q5119, Q5122, Q5128).
03For oncology indications (cervical cancer, endometrial cancer, metastatic colorectal cancer, non-small cell lung cancer, renal cell carcinoma, recurrent CNS tumor, soft tissue sarcoma, mesothelioma, ovarian/fallopian/peritoneal cancer, hepatocellular carcinoma), verify that members have documented intolerance or contraindication to Mvasi or Zirabev BEFORE approval—EXCEPT for Medicare Part B continuation-of-therapy requests within 365 days of prior approval, which are exempt from step-therapy.
04For pharmacy claims with macular indications (age-related macular degeneration, diabetic macular edema, macular retinal edema), verify appropriate diagnosis and approve for plan-year duration.
05Deny claims that do not meet clinical criteria or violate exclusions (e.g., bevacizumab with Vectibix/Erbitux for colorectal cancer, disease progression exclusions for lung cancer and renal cell carcinoma).
06Verify current applicability of this policy online before processing claims, as Humana updates policies regularly.
07Coordinate with providers to collect supporting documentation (diagnosis, prior therapy history, combination regimen details) required to meet approval criteria.
Codes mentioned
J9035Q5107Q5118Q5119Q5122Q5128
Original notice
Bevacizumab products (New)
mcp.humana.com · Always check the source before changing claims.
Related changes
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