`Q5160` Inj, jobevne, 10 mg

Injection, bevacizumab-nwgd (jobevne), biosimilar, 10 mg

Medicare coverage: Carrier judgment
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 230 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 230 units per day (clinical), rationale: CMS Policy
DME supplier: max 230 units per day (clinical), rationale: CMS Policy

Medicare pricing for Q5160

Medicare Part B drug payment limit (ASP, October 2026)

Q5160 payment limit: $82.139 per 10 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under Q5160 (CMS ASP NDC-HCPCS crosswalk, October 2026)

83257-0009-11 Jobevne, Biocon Biologics Inc.: 10 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 4 mL in 1 VIAL, SINGLE-DOSE)
83257-0010-11 Jobevne, Biocon Biologics Inc.: 40 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 16 mL in 1 VIAL, SINGLE-DOSE)

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for Q5160

42 of 42 payer prior-auth lists that name Q5160 require prior authorization or set conditions: Aetna, Arkansas Blue Cross and Blue Shield, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Shield of California Promise Health Plan, CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Healthcare of California, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Passport by Molina Healthcare (Kentucky), UnitedHealthcare, UnitedHealthcare Community Plan.

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, 2026	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	site of care: site-of-service review	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	site of care: site-of-service review	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		Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Commercial	All	prior auth required	site of care: drug and site of care	Oct 1, 2026	Participating provider precertification list for Aetna®
Aetna	Medicare Advantage	All	prior auth required	Step therapy applies	Aug 25, 2026	Aetna Medicare Part B drug list (partbname.xml)
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2026	Master Precertification List (For Health Care Providers)
Cigna	Basic Standard	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2026	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, 2026	Master Precertification List (For Health Care Providers)
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	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 Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jan 1, 2026	Molina Healthcare of Illinois Codification Grid Q3 2026
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 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
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required	cancer dx via Evolent	Jan 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	Apr 1, 2026	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	Apr 1, 2026	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	Apr 1, 2026	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	Apr 1, 2026	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

Payer coverage policies that name Q5160

Q5160 appears in 11 coverage policies from Aetna, 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	Bevacizumab for Non-Ocular Indications (0685)	covered if criteria are met	Apr 7, 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
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) oysk \| Hycleta™	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	Medicare Part B Step Therapy Programs (IAP.001.30) Non-Preferred	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Oncology Medication Clinical Coverage (2026D0030AR)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Oncology Medication Clinical Coverage (CS2026D0030AR)	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

Recent prior-auth changes

Oct 14, 2026: PA removed, Humana
Oct 1, 2026: PA added, Aetna
Oct 1, 2026: PA added, Aetna
Sep 1, 2026: PA added, Blue Shield of California Promise Health Plan
Aug 1, 2026: PA removed, Blue Shield of California Promise Health Plan
Jul 1, 2026: PA added, Blue Shield of California Promise Health Plan
Apr 1, 2026: PA added, UnitedHealthcare
Apr 1, 2026: PA added, HealthSpring
Apr 1, 2026: PA added, UnitedHealthcare
Apr 1, 2026: PA added, UnitedHealthcare Community Plan

Medicaid fee-for-service

Prior authorization required or conditional in MS, VT.

FL: $225.00 (physician_administered_drugs), effective Jan 1, 2026
IL: $11414.64 (practitioner), effective Apr 1, 2026
IN: $71.04 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
KS: $82.14 (asc, facility), effective Oct 1, 2026
MS: $67.50 (comprehensive, facility), effective Jan 1, 2026
NE: $82.23 (injectables), effective Jul 1, 2026
OH: $82.24 (provider_administered_drugs), effective Jul 1, 2026
OK: $82.24 (physician, non-facility), effective Jul 1, 2026
TX: $95.52 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Apr 1, 2026
VA: $82.23 (medical), effective Jul 1, 2026
VT: $64.13 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $82.24 (professional_administered_drugs), effective Jul 1, 2026
WY: $36.52 (outpatient_hospital_apc, Ambulatory Surgical Centers), effective Apr 1, 2026

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.

Q5160 Inj, jobevne, 10 mg