United Healthcare: Eylea Payer Policy

Created by C. Denise Burrell, Modified on Thu, 16 Jan at 5:25 PM by C. Denise Burrell

United Healthcare: Eylea Payer Policy (Beta Access)

TABLE OF CONTENTS

MEDICARE PART B
- Initial Approval Criteria
- Continuation Criteria
MEDICAID
COMMERCIAL

MEDICARE PART B

HCPCS Code(s):	J0178
Precertification Required?	Not Specified (Click Here For Full Policy)
Step Therapy Required?	Yes (Click Here For Full Policy)
Provider Fax Form:	Generic Form (✅ Available in SamaCare) Though this form is available in SamaCare, UHC may not accept faxed submissions. Instead, practices are encouraged to use the payer portal, which can be accessed directly through SamaCare!
FDA Approved Indications:	Neovascular (Wet) Age-Related Macular DegenerationMacular Edema Following Retinal Vein Occlusion Diabetic Macular Edema Diabetic Retinopathy
Recommended Dosage:	For ophthalmic intravitreal injection only. The recommended dose for EYLEA is 2 mg (0.05 mL) administered by intravitreal injection every 4 weeks (monthly) for the first 3 months, followed by 2 mg (0.05 mL) via intravitreal injection once every 8 weeks (2 months). Although EYLEA may be dosed as frequently as 2 mg every 4 weeks (monthly), additional efficacy was not demonstrated when EYLEA was dosed every 4 weeks compared to every 8 weeks.

Note: Step Therapy may be required, and its program policy applies to most UnitedHealthcare Medicare Advantage plans offered by UnitedHealthcare and its affiliates. Please refer to the Plan Exceptions outlined below:

Non-Employer Group Medicare Advantage

Erickson Advantage® plans: H5652-001 through H5652-008
UnitedHealthcare Medicare Direct (Private Fee-For-Service, PFFS): H5435-001, H5435- 024
Certain UnitedHealthcare Dual Complete and Dual Choice plans:
- Arizona: H0321-004
- District of Columbia: H2228-045, H2406-053, H2406-099, H7464-010
- Florida: H2509-001
- Minnesota: H0845-001, H7778-001, H7778-002
- New Jersey: H3113-005
- New York: H3387-013
- Tennessee: H0251-004
- Virginia: H7464-005, H7464-007
UnitedHealthcare Connected plans(Medicare-Medicaid)
- Massachusetts: H9239-001
- Ohio: H2531-001
- Texas: H7833-001
UnitedHealthcare Senior Care Options in Massachusetts: H2226-001, H2226-003

Employer Group Medicare Advantage

All Group HMO plans
Select Group PPO plans:
- Bristol-Myers Squibb: H2001-869
- Johnson & Johnson: H2001-869
- United Auto Workers (UAW) Trust: H2001-870
- U.S. Government of the Virgin Islands (USGVI): H2001-859, H2001-868
- Verizon: H2001-869

Initial Approval Criteria

- Not Specified

Continuation Criteria

- Not Specified

Medicare Part B Sources:

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-mp/medications-drugs-outpatient-partb.pdf

Additional Resources

MEDICAID

HCPCS Code(s):

J0178

Precertification Required?

Not Specified (Click Here for Full Policy)

Step Therapy Required?

Not Specified (Click Here for Full Policy)

Provider Fax Form:

Generic Form (✅ Available in SamaCare)

Though this form is available in SamaCare, UHC may not accept faxed submissions. Instead, practices are encouraged to use the payer portal, which can be accessed directly through SamaCare!

FDA Approved Indications:

Diabetic macular edema (DME)
Diabetic retinopathy (DR)
Macular edema secondary to branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO)
Neovascular age-related macular degeneration (nAMD)
Retinopathy of prematurity (ROP)

Recommended Dosage:

Diabetic macular edema	The recommended dose is 2 mg (0.05 mL) into affected eye(s) every 4 weeks (approximately every 28 days, monthly) for the first 20 weeks (5 months), then 2 mg every 8 weeks (2 months). Maximum of 12 doses per year per eye.
Diabetic retinopathy
Macular edema secondary to branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO)	The recommended dose is 2 mg (0.05 mL) once every 4 weeks. Maximum of 12 doses per year per eye.
Neovascular age-related macular degeneration	The recommended dose is 2 mg (0.05 mL) into affected eye(s) every 4 weeks (approximately every 28 days, monthly) for the first 12 weeks (3 months), followed by 2 mg once every 8 weeks (2 months). Maximum of 12 doses per year per eye

Note: This Medical Benefit Drug Policy does not apply to the states listed below; refer to the state-specific policy/guideline, if noted:

State	Policy/Guide Line
Indiana	Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Indiana Only)
Kansas	Refer to the state’s Medicaid clinical policy
Louisiana	Not Specified
North Carolina	Not Specified
Ohio	Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Ohio Only)
Pennsylvania	Refer to the state’s Medicaid clinical policy

Other Pertinent Information

Coverage for Eylea is provided for medically necessary treatments of the listed indications.

For neovascular (wet) age-related macular degeneration (AMD), compounded Avastin (bevacizumab) is the preferred VEGF inhibitor, followed by Eylea

Quantity Limits:
- Administration of intravitreal VEGF inhibitors is limited to 12 doses per year per eye, regardless of diagnosis.

Initial Approval Criteria

Both of the following:

Diagnosis; and
Intravitreal VEGF or dual VEGF/Ang-2 inhibitor administration is no more than 12 doses per year per eye, regardless of diagnosis

Continuation Criteria

Documentation of positive clinical response to anti-VEGF therapy.
Intravitreal VEGF or dual VEGF/Ang-2 inhibitor administration is no more than 12 doses per year per eye, regardless of diagnosis.

Medicaid Sources:

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/ophthalmologic-vascular-endothelial-growth-factor-inhibitors-cs.pdf

Additional Resources

COMMERCIAL

HCPCS Code(s):

J0178

Precertification Required?

Not Specified (Click Here For Full Policy)

Step Therapy Required?

Not Specified (Click Here For Full Policy)

Provider Fax Form:

Generic Form (✅ Available in SamaCare)

- Though this form is available in SamaCare, UHC may not accept faxed submissions. Instead, practices are encouraged to use the payer portal, which can be accessed directly through SamaCare!

FDA Approved Indications:

Diabetic macular edema (DME)
Diabetic retinopathy (DR)
Macular edema secondary to branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO)
Neovascular age-related macular degeneration (nAMD)
Retinopathy of prematurity (ROP)

Recommended Dosage:

Diabetic macular edema	The recommended dose is 2 mg (0.05 mL) into affected eye(s) every 4 weeks (approximately every 28 days, monthly) for the first 20 weeks (5 months), then 2 mg every 8 weeks (2 months). Maximum of 12 doses per year per eye.
Diabetic retinopathy
Macular edema secondary to branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO)	The recommended dose is 2 mg (0.05 mL) once every 4 weeks. Maximum of 12 doses per year per eye.
Neovascular age-related macular degeneration	The recommended dose is 2 mg (0.05 mL) into affected eye(s) every 4 weeks (approximately every 28 days, monthly) for the first 12 weeks (3 months), followed by 2 mg once every 8 weeks (2 months). Maximum of 12 doses per year per eye.

Note: Some Certificates of Coverage allow for coverage of experimental/investigational/unproven treatments for life-threatening illnesses when certain conditions are met. The member-specific benefit plan document must be consulted to make coverage decisions for this service. Some states mandate benefit coverage for off-label use of medications for some diagnoses or under some circumstances when certain conditions are met. Where such mandates apply, they supersede language in the benefit document or in the medical or drug policy. Benefit coverage for an otherwise unproven service for the treatment of serious rare diseases may occur when certain conditions are met. Refer to the Policy and Procedure addressing the treatment of serious rare diseases.

Other Pertinent Information

Coverage is contingent upon meeting medical necessity criteria outlined in the General and Diagnosis-Specific Requirements.

Quantity Limits:

A maximum of 12 doses per year per eye, regardless of the diagnosis

Initial Approval Criteria

Diagnosis confirmation.
Adherence to the dosing limit of 12 doses per year per eye

Continuation Criteria

Documentation of a positive clinical response to therapy.
Adherence to the dosing limit of 12 doses per year per eye

Commercial Sources:

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/ophthalmologic-vegf-inhibitors.pdf

Additional Resources:

⚠️ 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.

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United Healthcare: Eylea Payer Policy

United Healthcare: Eylea Payer Policy (Beta Access)

MEDICARE PART B

Initial Approval Criteria

Continuation Criteria

Medicare Part B Sources:

MEDICAID

Other Pertinent Information

Quantity Limits:

Administration of intravitreal VEGF inhibitors is limited to 12 doses per year per eye, regardless of diagnosis.

Initial Approval Criteria

Medicaid Sources:

COMMERCIAL

Other Pertinent Information

A maximum of 12 doses per year per eye, regardless of the diagnosis

Initial Approval Criteria

Continuation Criteria

Commercial Sources: