Humana: Pavblu Payer Policy (Beta Access)

TABLE OF CONTENTS

• Line of Business
• Diagnoses and Criteria
  • Neovascular (Wet) Age-Related Exudative Macular Degeneration (AMD)
  • Diabetic Macular Edema (DME)
  • Diabetic Retinopathy (DR)
  • Macular Edema following Retinal Vein Occlusion (RVO)
• Exclusions
• Additional Notes
• Sources

This policy details the coverage criteria for Aflibercept products (Pavblu™) based on specific diagnoses requiring treatment. Pavblu is a vascular endothelial growth factor (VEGF) inhibitor administered via intravitreal injection and requires prior authorization for approval.

Line of Business

This policy applies to Medicaid – Louisiana, with an effective date of January 1, 2023, a revision date of November 27, 2024, and a review date of November 20, 2024.

Diagnoses and Criteria

Neovascular (Wet) Age-Related Exudative Macular Degeneration (AMD)

1. Criteria for Approval:
   • The member has a diagnosis of neovascular (wet) age-related macular degeneration.
   • The member has a contraindication or intolerance to bevacizumab.
   • Alternatively, the member has had prior therapy with bevacizumab, and the provider attests that the member has not demonstrated a positive clinical response (e.g., improvement or maintenance in best-corrected visual acuity, visual field, or a reduction in the rate of vision decline).
2. Approval Duration:
   • Approval is for the plan year duration or as determined through clinical review.

Diabetic Macular Edema (DME)

1. Criteria for Approval:
   • The member has a diagnosis of diabetic macular edema.
   • The member has a contraindication or intolerance to bevacizumab.
   • Alternatively, the member has had prior therapy with bevacizumab, and the provider attests that the member has not demonstrated a positive clinical response (e.g., improvement or maintenance in best-corrected visual acuity, visual field, or a reduction in the rate of vision decline).
   • Step therapy requirements do not apply for members with 20/50 vision or worse.
2. Approval Duration:
   • Approval is for the plan year duration or as determined through clinical review.

Diabetic Retinopathy (DR)

1. Criteria for Approval:
   • The member has a diagnosis of diabetic retinopathy.
   • The member has a contraindication or intolerance to bevacizumab.
   • Alternatively, the member has had prior therapy with bevacizumab, and the provider attests that the member has not demonstrated a positive clinical response (e.g., improvement or maintenance in best-corrected visual acuity, visual field, or a reduction in the rate of vision decline).
   • Step therapy requirements do not apply for members with 20/50 vision or worse.
2. Approval Duration:
   • Approval is for the plan year duration or as determined through clinical review.

Macular Edema following Retinal Vein Occlusion (RVO)

1. Criteria for Approval:
   • The member has a diagnosis of macular edema following retinal vein occlusion.
   • The member has a contraindication or intolerance to bevacizumab.
   • Alternatively, the member has had prior therapy with bevacizumab, and the provider attests that the member has not demonstrated a positive clinical response (e.g., improvement or maintenance in best-corrected visual acuity, visual field, or a reduction in the rate of vision decline).
2. Approval Duration:
   • Approval is for the plan year duration or as determined through clinical review.

Exclusions

Pavblu is contraindicated in:

• Patients with active intraocular inflammation.
• Patients with ocular or periocular infections.

Concurrent use of Pavblu with other VEGF inhibitors is not recommended unless documentation specifies that the products are being used in different eyes.

Additional Notes

• Step therapy requirements are waived for Medicare Part B requests if the therapy is a continuation of treatment within the past 365 days.
• Dosage, quantity limits, and continuation criteria are not specified in the policy.

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