Bevacizumab (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev)

Medical Administration – intravenous

Diagnosis considered for coverage:

Metastatic Colorectal Cancer (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev)
- Indicated for the first- or second-line treatment of patients with metastatic colorectal cancer (mCRC) in combination with intravenous fluorouracil-based chemotherapy
- Indicated for the second-line treatment of patients with mCRC who have progressed on a first-line bevacizumab product-containing regimen in combination with fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin- based chemotherapy
- Limitations of Use: Bevacizumab is not indicated for adjuvant treatment of colon cancer
First-Line Non-Squamous Non-Small Cell Lung Cancer (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev)
- Indicated for the first-line treatment of patients with unresectable, locally advanced, recurrent or metastatic non– squamous non–small cell lung cancer (NSCLC) in combination with carboplatin and paclitaxel
Recurrent Glioblastoma (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev)
- Indicated for the treatment of recurrent glioblastoma (GBM) in adults
Metastatic Renal Cell Carcinoma (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev)
- Indicated for the treatment of metastatic renal cell carcinoma (mRCC) in combination with interferon alfa
Persistent, Recurrent, or Metastatic Cervical Cancer (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev)
- Indicated for the treatment of patients with persistent, recurrent, or metastatic cervical cancer in combination with paclitaxel and cisplatin or paclitaxel and topotecan
Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer (Alymsys, Avastin, Mvasi, Vegzelma, Zirabev)
- In combination with carboplatin and paclitaxel, followed by bevacizumab 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
- 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
- In combination with carboplatin and paclitaxel, or with carboplatin and gemcitabine, followed by bevacizumab 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)
- Indicated for the treatment of patients with unresectable or metastatic hepatocellular carcinoma (HCC) who have not received prior systemic therapy in combination with atezolizumab

Coverage Criteria:

For all indications:

One of the following:
- Both of the following:
  - Requested medication is being used for a Food and Drug Administration (FDA)-approved indication
  - Both of the following labeling requirements have been confirmed:
    - All components of the FDA approved indication are met (e.g., concomitant use, previous therapy requirements, age limitations, testing requirements, etc.)
    - Prescribed medication will be used at a dose which is within FDA recommendations
- Meets the off-label administrative guideline criteria; AND
For requests prescribed through the medical benefit: a medically appropriate reason is provided why the patient cannot use the medical group's preferred bevacizumab agent

Reauthorization Criteria:

For all indications:

Patient does not show evidence of progressive disease while on therapy; AND
For requests prescribed through the medical benefit: a medically appropriate reason is provided why the patient cannot use the medical group's preferred bevacizumab agent

Coverage Duration:

Initial: 1 year
Reauthorization: 1 year

Dosing:

For diagnosis of metastatic colorectal cancer:

Administered in combination with intravenous fluorouracil-based chemotherapy:
- 5 mg/kg intravenously every 2 weeks in combination with bolus-IFL
- 10 mg/kg intravenously every 2 weeks in combination with FOLFOX4
- 5 mg/kg intravenously every 2 weeks or 7.5 mg/kg intravenously every 3 weeks in combination with fluoropyrimidine-irinotecan-or fluoropyrimidine-oxaliplatin-based chemotherapy in patients who have progressed on a first-line bevacizumab product-containing regimen

For diagnosis of non–small cell lung cancer:

15 mg/kg intravenously every 3 weeks in combination with carboplatin and paclitaxel

For diagnosis of recurrent glioblastoma:

10 mg/kg intravenously every 2 weeks

For diagnosis of metastatic renal cell carcinoma:

10 mg/kg intravenously every 2 weeks in combination with interferon alfa

For diagnosis of cervical cancer:

15 mg/kg intravenously every 3 weeks in combination with paclitaxel and cisplatin or in combination with paclitaxel and topotecan

For diagnosis of epithelial ovarian, fallopian tube, or primary peritoneal cancer:

Stage III or IV Disease Following Initial Surgical Resection
- 15 mg/kg intravenously every 3 weeks in combination with carboplatin and paclitaxel for up to 6 cycles, followed by Avastin 15 mg/kg every 3 weeks as a single agent for a total of up to 22 cycles or until disease progression, whichever occurs earlier
Recurrent Disease
- Platinum Resistant
  - 10 mg/kg intravenously every 2 weeks in combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan (every week)
  - 15 mg/kg intravenously every 3 weeks in combination with topotecan (every 3 weeks)
- Platinum Sensitive
  - 15 mg/kg intravenously every 3 weeks, in combination with carboplatin and paclitaxel for 6 to 8 cycles, followed by Avastin 15 mg/kg every 3 weeks as a single agent until disease progression
  - 15 mg/kg intravenously every 3 weeks, in combination with carboplatin and gemcitabine for 6 to 10 cycles, followed by Avastin 15 mg/kg every 3 weeks as a single agent until disease progression

For diagnosis of Hepatocellular Carcinoma:

15 mg/kg intravenously after administration of 1,200 mg of atezolizumab intravenously on the same day, every 3 weeks until disease progression or unacceptable toxicity

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information:

Administer as an intravenous infusion
100 mg/4 mL (25 mg/mL) or 400 mg/16 mL (25 mg/mL) clear to opalescent, colorless to pale brown solution in a single-dose vial

Policy Updates:

3/1/2024 – New policy approved by WHA P&T Committee. (P&T, 02/20/2024)

References:

Avastin Prescribing Information. Genentech Inc. South San Francisco, CA. September 2022.
Mvasi Prescribing Information. Amgen Inc. Thousand Oaks, CA. November 2021.
Zirabev Prescribing Information. Pfizer Inc. New York, NY. May 2021.
U.S. Food and Drug Administration (FDA). Biosimilar and Interchangeable Products. Silver Spring, MD: FDA; October 23, 2017. Available at: https://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/TherapeuticBiologicApplications/Biosimilars/ucm580419.htm#biosimilar. Accessed February 21, 2023.
Alymsys Prescribing Information. Amneal Pharmaceuticals LLC. Bridgewater, NJ. April 2022.
Vegzelma Prescribing Information. Celltrion, Inc. Jersey City, NJ. February 2023.

Last review date: March 1, 2024