Humana: Avastin Payer Policy (Beta Access)

TABLE OF CONTENTS

• Humana: Avastin Payer Policy (Testing)
  • Line of Business
  • Precertification/Prior Authorization
  • Step Therapy
  • Diagnoses and Criteria
    • Age-Related Macular Degeneration (AMD)
    • Diabetic Macular Edema (DME)
    • Macular Edema Secondary to Retinal Vein Occlusion
  • Exclusions
  • Dosage and Administration
  • Additional Notes
  • Sources

This policy outlines the coverage criteria for Avastin®, a vascular endothelial growth factor (VEGF) inhibitor administered via intravenous solution. It is indicated for various oncological and ophthalmological conditions, including age-related macular degeneration (AMD) and diabetic macular edema (DME). Prior authorization is required for approval in certain cases.

Line of Business

This policy applies to the following line of business:

• Medicaid – Ohio

The effective date is March 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 covered oncology indications.
• Not Required:For ophthalmological conditions, including:
  • Age-related macular degeneration (AMD)
  • Diabetic macular edema (DME)
  • Macular edema secondary to retinal vein occlusion

Step Therapy

• Step therapy requirements are not explicitly specified for Avastin in this document. Clinical documentation is required to support the diagnosis and appropriateness of therapy.

Diagnoses and Criteria

Age-Related Macular Degeneration (AMD)

• Criteria:
  • A medical claim for Avastin is submitted for AMD.
  • No requirement to obtain prior authorization for medical claims related to AMD.
  • Medical claim edits and reviews apply to ensure proper diagnosis and dosing.
• Approval Duration: Initial plan year duration.

Diabetic Macular Edema (DME)

• Criteria:
  • A medical claim for Avastin is submitted for DME.
  • No requirement to obtain prior authorization for medical claims related to DME.
  • Medical claim edits and reviews apply to ensure proper diagnosis and dosing.
• Approval Duration: Initial plan year duration.

Macular Edema Secondary to Retinal Vein Occlusion

• Criteria:
  • A medical claim for Avastin is submitted for macular edema secondary to central or branch retinal vein occlusion.
  • No requirement to obtain prior authorization for medical claims related to macular edema.
  • Medical claim edits and reviews apply to ensure proper diagnosis and dosing.
• Approval Duration: Initial plan year duration.

Exclusions

• Avastin is contraindicated in:
  • Patients with recent hemoptysis.
  • Patients with a severe arterial thromboembolic event.
  • Patients with gastrointestinal perforation.
  • Patients with hypertensive crisis or hypertensive encephalopathy.
  • Concurrent use with Vectibix (panitumumab) or Erbitux (cetuximab).
  • Continued use after disease progression except for metastatic colorectal cancer.

Dosage and Administration

• Avastin is available as:
  • Intravenous solution: 25 mg/mL (100 mg or 400 mg vials).
• Administration:
  • Dosage and frequency depend on the specific indication and must align with FDA-approved recommendations or clinical guidelines for off-label uses such as ophthalmological conditions.

Additional Notes

• Avastin binds to VEGF, inhibiting its interaction with receptors on endothelial cells, preventing endothelial cell proliferation and new blood vessel formation.
• For ophthalmological indications, Avastin is widely supported by the American Academy of Ophthalmology as a cost-effective alternative to other VEGF inhibitors such as Lucentis and Eylea.

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