Priority Health: Lucentis Payer Policy (Beta Access)

TABLE OF CONTENTS

• Priority Health: Lucentis Payer Policy (Testing)
  • MEDICARE PART B
  • MEDICAID
    • Initial Approval Criteria
    • Continuation Criteria
  • COMMERCIAL
    • Initial Approval Criteria
    • Continuation Criteria

 MEDICARE PART B

Sources:

https://www.priorityhealth.com/-/media/priorityhealth/documents/drug-auth-forms/medicare-part-b-prior-authorization-criteria.pdf?rev=a79c9615271d418d8142ec756feb9556&hash=6BF12F7A8ED8934C07762E368297FE89

https://www.priorityhealth.com/-/media/priorityhealth/documents/pharmacy/medical-benefit-drug-list.xlsx?rev=8d6eb272df4d4f54be848c849b111626&hash=2ED5C6167163D06E77263259F0BD0E25

MEDICAID

Approval Timeframe:
Initial authorization: 1 year
Continuation authorization: 1 year

Initial Approval Criteria

• Documentation confirming diagnosis
• Patients currently receiving treatment with Lucentis and who have demonstrated an adequate response are not required to try Avastin.
  • Neovascular (wet) age-related macular degeneration (AMD):
    • Must first try Avastin (bevacizumab) for at least 3 consecutive months with failure to effectively improve baseline visual acuity and/or reduce fluid
    • Avastin is not required if patient has serous pigment epithelial detachment (PED), hemorrhagic PED, subretinal hemorrhage, or posterior uveal bleeding syndrome.
  • Macular edema following retinal vein occlusion (RVO)
    • Must first try Avastin (bevacizumab) for at least 3 consecutive months with failure to effectively improve baseline visual acuity and/or reduce fluid 
  • Diabetic macular edema (DME)
    • Must first try Avastin (bevacizumab) for at least 3 consecutive months with failure to effectively improve baseline visual acuity and/or reduce fluid 
  • Diabetic retinopathy (DR)
    • Must first try Avastin (bevacizumab) for at least 3 consecutive months with failure to effectively improve baseline visual acuity and/or reduce fluid 
  • Myopic Choroidal Neovascularization (mCNV)
    • Lucentis for mCNV may be authorized for a maximum of 1 injection per month up to a maximum of 3 months
      

Continuation Criteria

Documentation confirming diagnosis 

• Documentation showing the disease response as indicated by 
  • stabilization of visual acuity, or 
  • improvement in BCVA score when compared to baseline. 
    
• Therapy may be discontinued if patient is noncompliant with medical or pharmacologic therapy OR no demonstrable clinically significant improvement in condition has occurred after initiation of drug therapy. 

Sources:

https://www.priorityhealth.com/-/media/DAAE5553F48C4FDBA84BABBAE764BB84.pdf

COMMERCIAL

Initial Approval Criteria

Before this drug is covered, the patient must meet all of the following requirements: 

• Have one of the following diagnoses and meet any required criteria: 
• Neovascular (wet) age-related macular degeneration (AMD): 
  • ,First try Avastin (bevacizumab) for at least 3 consecutive months with failure to effectively improve baseline visual acuity and/or reduce fluid.
  • Avastin is not required if the patient has serous pigment epithelial detachment (PED), hemorrhagic PED, subretinal hemorrhage, or posterior uveal bleeding syndrome.
• Macular edema following retinal vein occlusion (RVO):
  • First, try Avastin (bevacizumab) for at least 3 consecutive months with failure to effectively improve baseline visual acuity and/or reduce fluid.
• Diabetic macular edema (DME): 
  • First, try Avastin (bevacizumab) for at least 3 consecutive months with failure to effectively improve baseline visual acuity and/or reduce fluid.
• Diabetic retinopathy:
  • First, try Avastin (bevacizumab) for at least 3 consecutive months with failure to effectively improve baseline visual acuity and/or reduce fluid.
• Myopic Choroidal Neovascularization (mCNV)
  • Lucentis for mCNV may be authorized for a maximum of 1 injection per month up to a maximum of 3 months.

Continuation Criteria

Disease response as indicated by stabilization of visual acuity or improvement in BCVA score when compared to baseline. 

Sources:

https://www.priorityhealth.com/-/media/81DACE8F00FF442799502209CC51780F.pdf