Anthem Blue Cross (HMO, PPO, EPO)
Mvasi 400 Mg/Ml Soln (Bevacizumab-Awwb)
Drugs for Cancer : Drugs for Cancer
  • Prior Authorization: Documented Diagnosis: Yes
    Duration: 1 year(s)

  • Cervical Cancer, Endometrial Cancer, Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO), Malignant Pleural Mesothelioma, Neovascular (Wet) Age-Related Macular Degeneration (AMD), NSCLC Systemic Therapy, Recurrent Glioblastoma:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Colorectal Cancer:
    Duration: 1 year(s)
    Documented Diagnosis Requirement: Explicitly Documented
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines;Payer Specific
    Documented Diagnosis: Yes
    Specialty Pharmacy is Required: Not Defined

    Kidney Cancer:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 1 of NCCN Guidelines;Payer Specific
    Supporting Documentation Requirements: Histology
    ECOG Score Requirement Included in Policy: N/A
    Policy Includes Reference to Coverage for Non Clear Cell Histology: Yes
    If Non-Clear Cell Histology is Referenced in Policy is There a Trial and Failure Requirement: No
    Concomitant Use With: 1 of Afinitor (everolimus);Interferon Alfa;Tarceva

    Ovarian Cancer:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines;Payer Specific
    Concomitant Therapy Requirement: Chemotherapy
    Diagnosis Types: 4 of Advanced disease;as a single agent;As a single agent, for maintenance, in stage III or IV disease following initial surgical resection or after combination regimen given first-line;epithelial ovarian, fallopian tube, or primary peritoneal cancer;maintenance therapy;Metastatic disease;Recurrent disease;Refractory disease;Relapsed disease;Stage III or IV disease following initial surgical resection