Humana: Eylea HD Payer Policy (Beta Access)

TABLE OF CONTENTS

• Neovascular (Wet) Age‐Related Exudative Macular Degeneration (AMD):
• Diabetic Macular Edema (DME)
• Macular Edema following Retinal Vein Occlusion (RVO)
• Retinopathy of Prematurity (ROP)

Neovascular (Wet) Age‐Related Exudative Macular Degeneration (AMD):

Criteria:

1. For Eylea, Eylea HD and Pabvlu requests: Has a diagnosis of neovascular (wet) age‐ related macular degeneration.
   1. Has a contraindication, or intolerance to bevacizumab.* 
      1. OR Has had prior therapy with bevacizumab* and provider attests that the member has NOT demonstrated a positive clinical response to bevacizumab (e.g., improvement or maintenance in best corrected visual acuity [BCVA] or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss). 
         1. *For Medicare Part B requests, the step therapy requirement does not apply if the request is a continuation of prior therapy within the past 365 days. 
            1. *Does not apply to Florida Medicaid requests. 

• Exclusion(s):
  • *For Medicare Part B requests, the step therapy requirement does not apply if the request is a continuation of prior therapy within the past 365 days. 
  • *Does not apply to Florida Medicaid requests. 

Initial Approval Criteria

Aflibercept Products (Eylea, Eylea HD, Pavblu) will be approved in plan year duration or as determined through clinical review.

Diabetic Macular Edema (DME)

Criteria

• For Eylea, Eylea HD and Pavblu requests: Has a diagnosis of Diabetic Retinopathy
  1. Has a contraindication, or intolerance to bevacizumab.^,* 
     1. OR Has had prior therapy with bevacizumab^ ,* and provider attests that the member has NOT demonstrated a positive clinical response to bevacizumab (e.g., improvement or maintenance in best corrected visual acuity [BCVA] or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss). 
        1. ^For Eylea and Pavblu requests: Step therapy requirement does not apply for members with 20/50 or worse vision.
• Exclusion(s):
  • *For Medicare Part B requests, the step therapy requirement does not apply if the request is a continuation of prior therapy within the past 365 days. 
  • *Does not apply to Florida Medicaid requests.

Initial Approval Criteria

Aflibercept Products (Eylea, Eylea HD, Pavblu) will be approved in plan year duration or as determined through clinical review.

Macular Edema following Retinal Vein Occlusion (RVO)

Criteria

For Eylea and Pavblu requests: Has a diagnosis of Macular Edema following Retinal Vein Occlusion (RVO)

1. Has a contraindication, or intolerance to bevacizumab.* 
   1. OR Has had prior therapy with bevacizumab* and provider attests that the member has NOT demonstrated a positive clinical response to bevacizumab (e.g., improvement or maintenance in best corrected visual acuity [BCVA] or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss).

• Exclusion(s):
  • *For Medicare Part B requests, the step therapy requirement does not apply if the request is a continuation of prior therapy within the past 365 days. 
  • *Does not apply to Florida Medicaid requests.

Initial Approval Criteria

Aflibercept Products (Eylea, Eylea HD, Pavblu) will be approved in plan year duration or as determined through clinical review.

Retinopathy of Prematurity (ROP)

For Eylea requests: Has a diagnosis of Retinopathy of Prematurity

Initial Approval Criteria

Aflibercept Products (Eylea) will be approved in plan year duration or as determined through clinical review.

Sources: https://mcp.humana.com/tad/tad_new/home.aspx?type=provider