Aetna: Lucentis Payer Policy (Beta Access)

TABLE OF CONTENTS

• Medicare Part B
  
• Commercial

 MEDICARE PART B

Note: Failure, contraindication, or intolerance to bevacizumab (Avastin) must be documented.

Other Pertinent Information

• Quantity Limits:

• Coverage is limited to the FDA-approved dosing schedules:
  • 0.5 mg intravitreal injection monthly for AMD, RVO, and mCNV.
  • 0.3 mg intravitreal injection monthly for DME and DR
• Exclusion(s):
  • Non-FDA-approved indications unless supported by Medicare-approved compendia.

Initial Approval Criteria

Authorization for 12 months may be granted for members meeting the following criteria:

1. Diagnosis of any of the following:
   • Neovascular (wet) age-related macular degeneration (AMD)
   • Macular edema following retinal vein occlusion (RVO)
   • Diabetic macular edema (DME)
   • Diabetic retinopathy (DR)
   • Myopic choroidal neovascularization (mCNV)
   • Retinopathy of prematurity
2. Prescribed dosing aligns with FDA-approved indications.
3. Documentation of step therapy (failure or intolerance to Avastin).

Continuation Criteria

Authorization for 12 months may be granted if all of the following are met:

1. Member is currently receiving therapy with Lucentis.
2. Treatment is for an approved indication (FDA or compendial).
3. Documentation of positive clinical response, such as:
   • Stabilization or improvement in visual acuity.

Sources:

1. Lucentis Medicare Part B Policy (PDF)
2. VEGF Inhibitors for Ocular Indications (PDF)

COMMERCIAL

Initial Approval Criteria

• The patient has a documented diagnosis of an FDA-approved indication (e.g., AMD, RVO, DME).
• Evidence of prior treatment failure, contraindication, or intolerance to Avastin or preferred therapies.

Continuation Criteria

• There is documented clinical benefit, such as improved or maintained visual acuity.
• Progression of symptoms has stabilized or decreased.

Resources:

• Aetna Medical Clinical Policy Bulletin - Vascular Endothelial Growth Factor Inhibitors for Ocular Indications

  • URL: https://www.aetna.com/cpb/medical/data/700_799/0701.html

• Lucentis Prescribing Information (for recommended dosage details)

  • URL: https://www.lucentis.com