Q5126 Inj alymsys 10 mgInjection, bevacizumab-maly, biosimilar, (alymsys), 10 mg
Q5126 payment limit: $79.982 per 10 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.
70121-1754-01 Alymsys, Amneal Pharmaceuticals, LLC: 10 billing units per package (1 VIAL in 1 CARTON / 4 mL in 1 VIAL)70121-1755-01 Alymsys, Amneal Pharmaceuticals, LLC: 40 billing units per package (1 VIAL in 1 CARTON / 16 mL in 1 VIAL)85006-1754-01 Alymsys, Valorum Biologics, LLC: 10 billing units per package (1 VIAL in 1 CARTON / 4 mL in 1 VIAL)85006-1755-01 Alymsys, Valorum Biologics, LLC: 40 billing units per package (1 VIAL in 1 CARTON / 16 mL in 1 VIAL)Status E: excluded from the PFS by regulation.
53 of 53 payer prior-auth lists that name Q5126 require prior authorization or set conditions: Aetna, Arkansas Blue Cross and Blue Shield, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, Blue Shield of California Promise Health Plan, CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Ohio, Molina Healthcare of Utah, Passport by Molina Healthcare (Kentucky), and others.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Arkansas Blue Cross and Blue Shield | Drugs under the medical benefit (not ASE/PSE or FEP, which use EBRx and Prime) | AR | prior auth under conditions | Not for ophthalmic indications; Non-preferred product | Jan 1, 2024 | Medical Benefit Pharmacy Prior Approval List |
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Step therapy | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Federal Employee Program (FEP) | AZ | prior auth required | Sep 1, 2026 | Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth under conditions | place of service 19, 22; site of care: outpatient hospital | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth under conditions | eviCore-delegated groups, all sites | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Teamsters group (TYW) | AZ | prior auth under conditions | place of service 19, 22; site of care: outpatient hospital | Sep 1, 2026 | Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026) |
| Blue Shield of California Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | Sep 1, 2026 | Medi-Cal Prior Authorization List | |
| Aetna | Medicare Advantage | All | prior auth required | Step therapy applies | Aug 25, 2026 | Aetna Medicare Part B drug list (partbname.xml) |
| Aetna | Medicare Advantage | All | prior auth under conditions | Oncology indications only | Oct 1, 2026 | Participating provider precertification list for Aetna® |
| Aetna | Commercial | All | prior auth under conditions | site of care: drug and site of care | Oct 1, 2026 | Participating provider precertification list for Aetna® |
| Cigna | ACA/IFP | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2023 | Master Precertification List (For Health Care Providers) |
| Cigna | Basic Standard | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2023 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2023 | Master Precertification List (For Health Care Providers) |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community Health Plans (BCCHP), Illinois Medicaid | IL | prior auth required | Carelon-managed | Aug 1, 2025 | Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 |
| Blue Cross and Blue Shield of Texas | Texas PA exemption (gold card), outpatient, fully insured | TX | prior auth required | Gold-card exemption available | Apr 1, 2023 | BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range) |
| HealthSpring | Medicare Advantage | All | prior auth required | Jan 1, 2025 | 2026 Q4 Prior Authorization List | |
| CarePlus Health Plans | CarePlus Health Plans | FL | prior auth required | Step therapy | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List We have updated our CarePlus Health Plans Prior Authorization and Notification List for CarePlus Medi |
| Humana | Humana D-SNP (FL) | FL | prior auth required | Step therapy | Jul 1, 2026 | H1036-280 Humana Fully Integrated Florida prior authorization and notification list |
| Humana | Humana D-SNP (IL) | IL | prior auth required | Step therapy | Jan 1, 2027 | Humana Dual Fully Integrated Illinois prior authorization and notification list |
| Humana | Humana D-SNP (IN) | IN | prior auth required | Step therapy | Jan 1, 2027 | Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes: |
| Humana | Humana D-SNP (MI) | MI | prior auth required | Step therapy | Oct 14, 2026 | Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL) |
| Humana | Humana D-SNP (SC) | SC | prior auth required | Step therapy | Jul 1, 2026 | Humana Dual Integrated South Carolina prior authorization and notification list |
| Humana | Humana D-SNP (VA) | VA | prior auth required | Step therapy | Jul 1, 2026 | Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia) |
| Humana | Humana Healthy Horizons | FL | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in Florida Prior Authorization and Notification List | |
| Humana | Humana Healthy Horizons | KY | prior auth required | Oct 7, 2026 | Humana Healthy Horizons in Kentucky Prior Authorization and Notification List | |
| Humana | Humana Healthy Horizons | LA | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in Louisiana Prior Authorization and Notification List | |
| Humana | Humana Healthy Horizons | OH | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in Ohio prior authorization and notification List | |
| Humana | Humana Healthy Horizons | OK | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List | |
| Humana | Humana Healthy Horizons | SC | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in South Carolina prior authorization and notification list | |
| Humana | Humana Healthy Horizons | VA | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list | |
| Humana | Humana MA and D-SNP | All | prior auth required | Step therapy | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes: |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 | |
| Molina Healthcare of California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | Jan 1, 2022 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth required | Bevacizumab when billed for intraocular injection does not require PA | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | Bevacizumab when billed for intraocular injection does not require PA | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth required | cancer dx via Evolent | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Utah | Medicaid | UT | prior auth required | Jan 1, 2025 | Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | cancer dx via Evolent | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth required | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Individual Exchange plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Texas CHIP | TX | prior auth under conditions | site of care: outpatient | May 1, 2023 | Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care |
| UnitedHealthcare Community Plan | Texas STAR | TX | prior auth under conditions | site of care: outpatient | May 1, 2023 | Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h |
| UnitedHealthcare Community Plan | Texas STAR Kids | TX | prior auth under conditions | site of care: outpatient | May 1, 2023 | Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki |
| UnitedHealthcare Community Plan | Texas STAR+PLUS | TX | prior auth under conditions | site of care: outpatient | May 1, 2023 | Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Hawaii (QUEST Integration) | HI | prior auth under conditions | site of care: outpatient | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Kentucky | KY | prior auth under conditions | site of care: outpatient | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026 |
Q5126 appears in 23 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare, Wellmark Blue Cross Blue Shield.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Atezolizumab (Tecentriq) and Atezolizumab and Hyaluronidase-tqjs (Tecentriq Hybreza) (0909) | listed, no stance | Sep 28, 2026 | payer document |
| Aetna | Bevacizumab for Non-Ocular Indications (0685) | covered if criteria are met | Apr 7, 2026 | payer document |
| Aetna | Dexamethasone Ophthalmic Implant (Ozurdex) and Insert (Dextenza) (0795) | listed, no stance | Oct 5, 2026 | payer document |
| Aetna | Indocyanine Green Angiography (0111) | listed, no stance | Mar 18, 2026 | payer document |
| Aetna | Irinotecan Liposome Injection (Onivyde) (0902) | listed, no stance | Feb 24, 2026 | payer document |
| Aetna | Pembrolizumab Products (Keytruda and Keytruda Qlex) (0890) | listed, no stance | Jul 14, 2026 | payer document |
| Aetna | Vascular Endothelial Growth Factor Inhibitors for Ocular Indications (0701) | covered if criteria are met | Oct 5, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Biosimilar Medications (L.5.01.593) | listed, no stance | payer document | |
| Blue Cross & Blue Shield of Mississippi | Biosimilar Medications (S.5.01.593) | listed, no stance | payer document | |
| Blue Cross & Blue Shield of Mississippi | Intravitreal Angiogenesis Inhibitors (L.5.01.569) | not covered | payer document | |
| Blue Cross & Blue Shield of Mississippi | Intravitreal Angiogenesis Inhibitors (S.5.01.569) | not covered | payer document | |
| Centene | Bevacizumab (Alymsys, Avastin, Avzivi, Jobevne, Mvasi, Vegzelma, Zirabev) (CP.PHAR.93) | covered if criteria are met | Nov 1, 2025 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Oncology and Supportive Care Medications (RX502.061) Code | Generic | Brand | listed, no stance | Jan 1, 2027 | payer document |
| Premera Blue Cross | (effective January 1, 2027) Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment (5.01.517) | listed, no stance | Sep 8, 2026 | payer document |
| UnitedHealthcare | Maximum Dosage and Frequency (CS2026D0034AV) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Maximum Dosage and Frequency (2026D0034AU) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Maximum Dosage and Frequency (for Ohio Only) (CSOH2026D0034.K) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Maximum Dosage and Frequency (for Pennsylvania Only) (CSPA2026D0034AS) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Medicare Part B Step Therapy Programs (IAP.001.30) Non-Preferred | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Oncology Medication Clinical Coverage (CS2026D0030AR) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Oncology Medication Clinical Coverage (2026D0030AR) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Oncology Medication Clinical Coverage (for Pennsylvania Only) (CSPA2026D0030II) | listed, no stance | Jul 1, 2026 | payer document |
| Wellmark Blue Cross Blue Shield | Bevacizumab (05.04.24) | listed, no stance | Aug 1, 2026 | payer document |
Prior authorization required or conditional in MS.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.