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 Retinal Edema
  • 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 oncology and ophthalmology conditions. Prior authorization is required for some indications, depending on the line of business.

Line of Business

This policy applies to the following lines of business:

• Medicare
• Medicaid – Florida
• Commercial
• Medicaid – Kentucky

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

Precertification/Prior Authorization

• Required for Pharmacy Claims:
  • Prior authorization is required for any pharmacy claim for Avastin and other bevacizumab products.
• Medical Claims:
  • No prior authorization required for medical claims related to age-related macular degeneration (AMD), diabetic macular edema (DME), or macular retinal edema.
  • Medical claim edits and reviews will still apply to ensure proper diagnosis and dosing.

Step Therapy

• Step Therapy Requirements:
  • For Medicare Part B requests, step therapy does not apply if the request is a continuation of therapy within the past 365 days.
  • Florida Medicaid requests are exempt from step therapy requirements.

Diagnoses and Criteria

Age-Related Macular Degeneration (AMD)

• Criteria:
  • The member is diagnosed with AMD.
  • No prior authorization required for medical claims.
  • Pharmacy claims require prior authorization.
• Approval Duration: Initial plan year duration.

Diabetic Macular Edema (DME)

• Criteria:
  • The member is diagnosed with DME.
  • No prior authorization required for medical claims.
  • Pharmacy claims require prior authorization.
• Approval Duration: Initial plan year duration.

Macular Retinal Edema

• Criteria:
  • The member is diagnosed with macular retinal edema secondary to central or branch retinal vein occlusion.
  • No prior authorization required for medical claims.
  • Pharmacy claims require prior authorization.
• Approval Duration: Initial plan year duration.

Exclusions

• Avastin is contraindicated in:
  • Members with recent hemoptysis.
  • Members experiencing severe arterial thromboembolic events or hypertensive crises.
  • Members with gastrointestinal perforation or fistula formation involving internal organs.
  • Members undergoing anticoagulation for bleeding disorders.
  • Members continuing after disease progression (except metastatic colorectal cancer).

Dosage and Administration

• Avastin is available as:
  • Intravenous solution: 25 mg/mL (100 mg or 400 mg vials).
• Administration:
  • Dosage varies based on the condition and must comply with FDA-approved guidelines or clinical standards.

Additional Notes

• Avastin binds to VEGF, preventing angiogenesis and vascular permeability.
• For ophthalmologic conditions, it is supported as a cost-effective option for AMD, DME, and other retinal conditions by clinical guidelines and expert consensus.

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