Aetna: Avastin (Ophthalmic) Payer Policy (Beta Access)

TABLE OF CONTENTS

• Commercial
• Medicare Part B

 COMMERCIAL

Note:  Avastin is the preferred lower-cost VEGF inhibitor compared to higher-cost alternatives like Lucentis, Cimerli, Byooviz, and other VEGF inhibitors.

Other Pertinent Information

• Exclusion(s):

     All other indications not listed above are considered:

• Not medically necessary
• Experimental, investigational, or unproven

Initial Approval Criteria

Intravitreal bevacizumab (Avastin) is considered medically necessary for the following indications:

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

Continuation Criteria

Continuation of Avastin therapy is considered medically necessary for the indications listed above when the member has demonstrated a positive clinical response to therapy, such as:

• Improvement or maintenance in best corrected visual acuity (BCVA)
• Reduction in the rate of vision decline
• Reduction in the risk of more severe vision loss

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