Health Net
Mvasi 400 Mg/Ml Soln (Bevacizumab-Awwb)
Drugs for Cancer : Drugs for Cancer
  • Prior Authorization: Cervical Cancer, Colorectal Cancer, Kidney Cancer, NSCLC Systemic Therapy, Ovarian Cancer, Recurrent Glioblastoma:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    Reauthorization Required: Yes

    Endometrial Cancer, Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO), Neovascular (Wet) Age-Related Macular Degeneration (AMD):
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    Reauthorization Required: Yes

  • Cervical Cancer, NSCLC Systemic Therapy, Recurrent Glioblastoma:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year

    Colorectal Cancer:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis Requirement: Explicitly Documented
    Medical Test Required: Yes
    Specialist Type(s): Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year
    Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
    Documented Diagnosis: Yes
    Specialty Pharmacy is Required: Not Defined

    Endometrial Cancer:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year

    Kidney Cancer:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year
    Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
    Supporting Documentation Requirements: 2 of Chart Notes;Lab Tests
    ECOG Score Requirement Included in Policy: N/A
    Policy Includes Reference to Coverage for Non Clear Cell Histology: No
    If Non-Clear Cell Histology is Referenced in Policy is There a Trial and Failure Requirement: No
    Concomitant Use With: 1 of Afinitor (everolimus);Erlotinib;Interferon Alfa

    Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO), Neovascular (Wet) Age-Related Macular Degeneration (AMD):
    Age Requirement: >= 18
    Duration: 1 plan year
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year

    Ovarian Cancer:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year
    Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
    Concomitant Therapy Requirement: 1 of carboplatin and gemcitabine;paclitaxel;paclitaxel and carboplatin;pegylated liposomal doxorubicin;topotecan
    Diagnosis Types: 2 of as a single agent;epithelial ovarian, fallopian tube, or primary peritoneal cancer;platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer;platinum-sensitive recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer;Stage III or IV disease following initial surgical resection;Treated with no more than 2 prior chemotherapy regimens
    Supporting Documentation Requirements: Chart Notes