Anthem: Avastin Payer Policy (Beta Access)

Note:  Avastin is considered a preferred agent.

Other Pertinent Information

• Avastin is often obtained from compounding pharmacies for ophthalmic use.
• FDA warnings emphasize using products from accredited compounding pharmacies to avoid contamination risks.

• Quantity Limits:

  • 1.25 mg per eye – Each eye may be treated as frequently as every 4 weeks. 

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

Initial Approval Criteria

Authorization for 12 months may be granted if the member has a diagnosis of:

1. Neovascular (wet) age-related macular degeneration (AMD)
2. Diabetic macular edema (DME)
3. Proliferative or moderate to severe non-proliferative diabetic retinopathy
4. Macular edema from central or branch retinal vein occlusion
5. Neovascular glaucoma
6. Choroidal neovascularization due to myopic degeneration or other causes
7. Radiation retinopathy
8. Retinopathy of prematurity

Continuation Criteria

Authorization for 12 months may be granted if:

1. The member is currently receiving therapy with Avastin.
2. There is documentation of positive clinical response to therapy.

Sources:

https://www.anthem.com/ms/pharmacyinformation/VEGF.pdf

Additional Reources:

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