Effective with date of service April 17, 2023, NC Medicaid covers bevacizumab-adcd injection, for intravenous use (Vegzelma) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code Q5129 - Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg.
Strength/Package Sizes: Injection: 100 mg/4 mL (25 mg/mL) or 400 mg/16 mL (25 mg/mL) in a single-dose vial
Indicated for the treatment of:
- Metastatic colorectal cancer, in combination with intravenous fluorouracil-based chemotherapy for first- or second-line treatment.
- Metastatic colorectal cancer, in combination with fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy for second-line treatment in patients who have progressed on a first-line bevacizumab product-containing regimen.
Limitations of Use: Vegzelma is not indicated for adjuvant treatment of colon cancer.
- Unresectable, locally advanced, recurrent, or metastatic non-squamous non-small cell lung cancer, in combination with carboplatin and paclitaxel for first-line treatment.
- Recurrent glioblastoma in adults.
- Metastatic renal cell carcinoma in combination with interferon alfa.
- Persistent, recurrent, or metastatic cervical cancer, in combination with paclitaxel and cisplatin, or paclitaxel and topotecan.
- Epithelial ovarian, fallopian tube, or primary peritoneal cancer:
- in combination with carboplatin and paclitaxel, followed by Vegzelma as a single agent, for stage III or IV disease following initial surgical resection
- in combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan for platinum-resistant recurrent disease in patients who received no more than 2 prior chemotherapy regimens
- in combination with carboplatin and paclitaxel or carboplatin and gemcitabine, followed by Vegzelma as a single agent, for platinum-sensitive recurrent disease
- In combination with atezolizumab for the treatment of patients with unresectable or metastatic hepatocellular carcinoma (HCC) who have not received prior systemic therapy.
Recommended Dose:
Metastatic colorectal cancer
- 5 mg/kg every 2 weeks with bolus-IFL
- 10 mg/kg every 2 weeks with FOLFOX4
- 5 mg/kg every 2 weeks or 7.5 mg/kg every 3 weeks with fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy after progression on a first-line bevacizumab product containing regimen
First-line non-squamous non-small cell lung cancer
- 15 mg/kg every 3 weeks with carboplatin and paclitaxel
Recurrent glioblastoma
- 10 mg/kg every 2 weeks
Metastatic renal cell carcinoma
- 10 mg/kg every 2 weeks with interferon alfa
Persistent, recurrent, or metastatic cervical cancer
- 15 mg/kg every 3 weeks with paclitaxel and cisplatin or paclitaxel and topotecan
Stage III or IV epithelial ovarian, fallopian tube, or primary peritoneal cancer following initial surgical resection
- 15 mg/kg every 3 weeks with carboplatin and paclitaxel for up to 6 cycles, followed by 15 mg/kg every 3 weeks as a single agent, for a total of up to 22 cycles
Platinum-resistant recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer
- 10 mg/kg every 2 weeks with paclitaxel, pegylated liposomal doxorubicin, or topotecan given every weeks
- 15 mg/kg every 3 weeks with topotecan given every 3 weeks
Platinum-sensitive recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer
- 15 mg/kg every 3 weeks with carboplatin and paclitaxel for 6-8 cycles, followed by 15 mg/kg every 3 weeks as a single agent
- 15 mg/kg every 3 weeks with carboplatin and gemcitabine for 6-10 cycles followed by 15 mg/kg every 3 weeks as a single agent
Hepatocellular Carcinoma
- 15 mg/kg after administration of 1,200 mg of atezolizumab every 3 weeks
See full prescribing information for further detail.
For Medicaid Billing
- The ICD-10-CM diagnosis codes required for billing are:
- Colorectal cancer:
- C18.0 - Malignant neoplasm of cecum;
- C18.1 - Malignant neoplasm of appendix;
- C18.2 - Malignant neoplasm of ascending colon;
- C18.3 - Malignant neoplasm of hepatic flexure;
- C18.4 - Malignant neoplasm of transverse colon;
- C18.5 - Malignant neoplasm of splenic flexure;
- C18.6 - Malignant neoplasm of descending colon;
- C18.7 - Malignant neoplasm of sigmoid colon;
- C18.8 - Malignant neoplasm of overlapping sites of colon;
- C19 - Malignant neoplasm of rectosigmoid junction;
- C20 - Malignant neoplasm of rectum;
- C21.8 - Malignant neoplasm of overlapping sites of rectum, anus and anal canal;
- Non-small cell lung cancer:
- C33 - Malignant neoplasm of trachea;
- C34.01 - Malignant neoplasm of right main bronchus;
- C34.02 - Malignant neoplasm of left main bronchus;
- C34.11 - Malignant neoplasm of upper lobe, right bronchus or lung;
- C34.12 - Malignant neoplasm of upper lobe, left bronchus or lung;
- C34.2 - Malignant neoplasm of middle lobe, bronchus or lung;
- C34.31 - Malignant neoplasm of lower lobe, right bronchus or lung;
- C34.32 - Malignant neoplasm of lower lobe, left bronchus or lung;
- C34.81 - Malignant neoplasm of overlapping sites of right bronchus and lung;
- C34.82 - Malignant neoplasm of overlapping sites of left bronchus and lung;
- Cervical cancer:
- C53.0 - Malignant neoplasm of endocervix;
- C53.1 - Malignant neoplasm of exocervix;
- C53.8 - Malignant neoplasm of overlapping sites of cervix uteri;
- Renal cell carcinoma:
- C64.1 - Malignant neoplasm of right kidney, except renal pelvis;
- C64.2 - Malignant neoplasm of left kidney, except renal pelvis;
- C65.1 - Malignant neoplasm of right renal pelvis;
- C65.2 - Malignant neoplasm of left renal pelvis;
- Glioblastoma:
- C71.0 - Malignant neoplasm of cerebrum, except lobes and ventricles;
- C71.1 - Malignant neoplasm of frontal lobe;
- C71.2 - Malignant neoplasm of temporal lobe;
- C71.3 - Malignant neoplasm of parietal lobe;
- C71.4 - Malignant neoplasm of occipital lobe;
- C71.5 - Malignant neoplasm of cerebral ventricle;
- C71.6 - Malignant neoplasm of cerebellum;
- C71.7 - Malignant neoplasm of brain stem;
- C71.8 - Malignant neoplasm of overlapping sites of brain;
- Epithelial ovarian, fallopian tube and primary peritoneal cancer:
- C48.1 - Malignant neoplasm of specified parts of peritoneum;
- C48.8 - Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum;
- C56.1 - Malignant neoplasm of right ovary;
- C56.2 - Malignant neoplasm of left ovary;
- C56.3 - Malignant neoplasm of bilateral ovaries;
- C57.01 - Malignant neoplasm of right fallopian tube;
- C57.02 - Malignant neoplasm of left fallopian tube;
- C79.61 - Secondary malignant neoplasm of right ovary;
- C79.62 - Secondary malignant neoplasm of left ovary;
- C79.63 - Secondary malignant neoplasm of bilateral ovaries;
- HCC:
- C22.0 - Liver cell carcinoma;
- C22.8 - Malignant neoplasm of liver, primary, unspecified as to type
- Colorectal cancer:
- Providers must bill with HCPCS code: Q5129 - Injection, bevacizumab-adcd (vegzelma), biosimilar,
- 10 mg
- One Medicaid unit of coverage is: 10 mg
- The maximum reimbursement rate per unit is: $73.15920
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 72606-0011-01, 72606-0012-01
- The NDC units should be reported as "UN1."
- For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update and PADP Clinical Coverage Policy 1B, Attachment A, H.7 on Medicaid's website.
- Providers shall bill their usual and customary charge for non-340B drugs.
- PADP reimburses for drugs billed for Medicaid beneficiaries by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the "UD" modifier on the drug detail.
- The fee schedule for the PADP is available on the NC Medicaid Fee Schedule & Covered Code portal.
Contact:
NCTracks Call Center: 800-688-6696