Humana: Cimerli Payer Policy (Beta Access)

TABLE OF CONTENTS

• Line of Business
• Precertification/Prior Authorization
• Step Therapy
• 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)
  • Myopic Choroidal Neovascularization (mCNV)
• Exclusions
• Additional Notes
• Sources

This policy outlines the coverage criteria for Cimerli™, a recombinant monoclonal antibody and vascular endothelial growth factor (VEGF) inhibitor administered via intravitreal injection. It is indicated for multiple ophthalmological conditions and requires prior authorization for approval.

Line of Business

This policy applies to the following line of business:

• Medicaid – Louisiana

The effective date is October 1, 2023, with a revision date of February 28, 2024, and a review date of February 21, 2024.

Precertification/Prior Authorization

• Required: Yes, prior authorization is required for all covered indications.

Step Therapy

• Members must have a contraindication or intolerance to bevacizumab OR must have had prior therapy with bevacizumab, and the provider must attest 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).

Diagnoses and Criteria

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

• The member has a diagnosis of neovascular (wet) age-related macular degeneration.
• Step therapy requirements apply as outlined above.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Diabetic Macular Edema (DME)

• The member has a diagnosis of diabetic macular edema.
• Step therapy requirements apply as outlined above.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Diabetic Retinopathy (DR)

• The member has a diagnosis of diabetic retinopathy.
• Step therapy requirements apply as outlined above.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Macular Edema Following Retinal Vein Occlusion (RVO)

• The member has a diagnosis of macular edema following retinal vein occlusion.
• Step therapy requirements apply as outlined above.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Myopic Choroidal Neovascularization (mCNV)

• The member has a diagnosis of myopic choroidal neovascularization.
• Step therapy requirements apply as outlined above.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Exclusions

• Cimerli is contraindicated in:
  • Patients with ocular or periocular infections.
• Concurrent use of Cimerli with other VEGF inhibitors is not recommended unless documentation specifies that the products are being used in different eyes.

Additional Notes

• Dosage, quantity limits, and continuation criteria are not specified in the policy.

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