Anthem: Lucentis Payer Policy (Beta Access)

Note:  Lucentis is subject to step therapy requirements as a non-preferred agent.Trial and failure, intolerance, or contraindication to a preferred agent are required before approval.
Preferred Agents include:
Avastin
Byooviz
Cimerli
Eylea

Other Pertinent Information

Lucentis is a non-preferred agent, and step therapy applies unless specified otherwise.

• Quantity Limits:

  • DME and diabetic retinopathy: 0.3 mg per eye every 4 weeks
  • Other indications: 0.5 mg per eye every 4 weeks

• Exclusion(s):
  • Indications not listed above are considered not medically necessary. 

Initial Approval Criteria

Authorization may be approved for 12 months when the following criteria are met:

1. The member has a diagnosis of one of the following:
   • Diabetic macular edema (DME)
   • Diabetic retinopathy
   • Neovascular (wet) age-related macular degeneration
   • Macular edema following BRVO or CRVO
   • Myopic choroidal neovascularization
   • Radiation retinopathy

Continuation Criteria

Authorization may be approved for 12 months if:

1. The member is currently receiving therapy with Lucentis.
2. Documentation of positive clinical response is provided, such as improvement or maintenance of best corrected visual acuity (BCVA).

Sources:

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

Additonal 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