Aetna: Cimerli Payer Policy (Beta Access)

TABLE OF CONTENTS

• Medicare Part B
  
• Commercial

 MEDICARE PART B

Other Pertinent Information

Submissions for non-listed indications must include supporting evidence from Medicare-approved compendia, such as:

• National Comprehensive Cancer Network (NCCN)
• Micromedex DrugDex
• American Hospital Formulary Service (AHFS-DI)
• Lexi-Drugs

• Exclusion(s):
  • Non-FDA-approved indications unless supported by Medicare-approved compendia. 

Initial Approval Criteria

Authorization of 12 months may be granted for the following indications:

1. Neovascular (wet) age-related macular degeneration
2. Macular edema following retinal vein occlusion (RVO)
3. Myopic choroidal neovascularization (mCNV)
4. Diabetic macular edema (DME)
5. Diabetic retinopathy (DR)
6. Retinopathy of prematurity

Continuation Criteria

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

1. The member is currently receiving therapy with Cimerli.
2. Cimerli is being used for an approved indication listed in the Initial Approval Criteria.
3. The medication has been effective for treating the diagnosis or condition.

Sources:

https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/Lucentis-Byooviz-Cimerli-2508-A-Aetna-MedB.pdf

COMMERCIAL

Other Pertinent Information

• Quantity Limits:

• Exclusion(s):
  • All other indications are considered not medically necessary. 

Initial Approval Criteria

Authorization is considered medically necessary for 12 months for members with the following conditions:

1. Neovascular (wet) age-related macular degeneration (AMD)
2. Macular edema following retinal vein occlusion (RVO)
3. Diabetic macular edema (DME)
4. Diabetic retinopathy (DR)
5. Myopic choroidal neovascularization (mCNV)

Continuation Criteria

Authorization is considered medically necessary for 12 months if:

1. The member is currently receiving therapy with Cimerli.
2. The member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in best corrected visual acuity [BCVA], or reduction in vision loss progression).

Sources:

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