Humana: Lucentis Payer Policy (Beta Access)

TABLE OF CONTENTS

• Humana: Lucentis Payer Policy (Testing)
  • Line of Business
  • Precertification/Prior Authorization
  • 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
  • Dosage and Administration
  • Additional Notes
  • Sources

This policy outlines the coverage criteria for Lucentis®, 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 – Indiana

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

Precertification/Prior Authorization

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

Diagnoses and Criteria

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

• The member has a diagnosis of neovascular (wet) age-related macular degeneration.
• The member has a contraindication or intolerance to bevacizumab, OR 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 (BCVA), visual field, or a reduction in the rate of vision decline or risk of severe vision loss).
• 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.
• The member has a contraindication or intolerance to bevacizumab, OR 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 BCVA, visual field, or a reduction in the rate of vision decline or risk of severe vision loss).
• 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.
• The member has a contraindication or intolerance to bevacizumab, OR 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 BCVA, visual field, or a reduction in the rate of vision decline or risk of severe vision loss).
• 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.
• The member has a contraindication or intolerance to bevacizumab, OR 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 BCVA, visual field, or a reduction in the rate of vision decline or risk of severe vision loss).
• 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.
• The member has a contraindication or intolerance to bevacizumab, OR 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 BCVA, visual field, or a reduction in the rate of vision decline or risk of severe vision loss).
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Exclusions

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

Dosage and Administration

• Lucentis is available in the following forms:
  • 0.5 mg (10 mg/mL) solution for intravitreal injection (single-use syringe or vial).
  • 0.3 mg (6 mg/mL) solution for intravitreal injection (single-use syringe or vial).

Additional Notes

• Lucentis binds to and inhibits VEGF-A to reduce the growth of abnormal blood vessels and leakage in the retina.
• Dosage limits beyond those specified for FDA-approved indications are not detailed in this policy.

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