Anthem: Cimerli Payer Policy (Beta Access)
| HCPCS Code(s): | Q5128 |
| Precertification Required? | ✅ Yes(Click Here for Full Policy) |
| Step Therapy Required? | ✅ Yes (Click Here for Full Policy) |
| Provider Fax Form: | ✅ Available in SamaCare |
| FDA Approved Indications: |
|
| Recommended Dosage: | Not Specified |
Note: Cimerli is considered a non-preferred agent. Members must trial and fail or have intolerance to one preferred agent, including: Avastin (bevacizumab), Byooviz (ranibizumab-nuna), Eylea (aflibercept).
Other Pertinent Information
Cimerli is designated by the FDA as interchangeable with Lucentis.
It is used as a biosimilar for intravitreal injection therapy
.
Quantity Limits:
0.5 mg per eye, each eye may be treated as frequently as every 4 weeks.
- Exclusion(s):
- All other indications not listed are considered not medically necessary.
Initial Approval Criteria
Authorization for 12 months may be granted if the member meets the following criteria:
- Diagnosis of one of the following:
- Neovascular (wet) age-related macular degeneration (AMD)
- Diabetic macular edema (DME)
- Diabetic retinopathy
- Macular edema following retinal vein occlusion (RVO)
Continuation Criteria
Authorization for 12 months may be granted if:
- The member is currently receiving therapy with Cimerli.
- Documentation of a positive clinical responseis provided, such as:
- Improvement or maintenance of best corrected visual acuity (BCVA).
Sources: https://www.anthem.com/ms/pharmacyinformation/VEGF.pdf
Additional Resources
Medical Specialty Precertification Drug List: https://file.anthem.com/06347MUPENABS.pdf
Medical Step Therapy Drug List: https://file.anthem.com/A02605ANPENABS.pdf
Site of Care Drug List: https://file.anthem.com/06346MUPENABS.pdf
⚠️ Disclaimer: This article is a policy summary and does not guarantee coverage or approval.
Policies may vary based on plan, payer-specific rules, state or regional requirements, benefit structure, formulary placement, and patient-specific considerations like diagnosis or clinical history. Always review the full policy and confirm details directly with the payer to ensure compliance.
We're here to guide you through your prior authorization quest!
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