United Healthcare: Eylea HD Payer Policy (Testing)

TABLE OF CONTENTS

• United Healthcare: Eylea HD Payer Policy (Testing)
  • MEDICARE PART B
  • Other Pertinent Information:
  • Dosage and Administration:
  • Quantity Limits:
  • Initial Approval Criteria
  • Continuation Criteria
  • MEDICAID
    • Other Pertinent Information
    • Initial Approval Criteria
  • COMMERCIAL
    • Other Pertinent Information
    • Initial Approval Criteria
    • Continuation Criteria
    • Commercial Sources

MEDICARE PART B

Step therapy applies to Eylea HD

• Trial of at least three consecutive doses given monthly of compounded Avastin (bevacizumab) resulting in minimal clinical response.
• History of use of Eylea, resulting in minimal clinical response to therapy, or
• Documented intolerance, contraindication, or adverse events to compounded Avastin and Eylea.

Other Pertinent Information:

• Eylea HD is classified as a non-preferred product under the Medicare Advantage Step Therapy Program. 

Dosage and Administration:

• Initial Therapy: Administered as monthly intravitreal injections for the first three months.
• Maintenance Therapy: Administered every 8 to 12 weeks, based on clinical response.

Quantity Limits:

• Quantity limits are based on the dosing schedule: no more than 12 doses per year per eye. 

Initial Approval Criteria

• Diagnosis of Neovascular (Wet) Age-Related Macular Degeneration.
• Trial and failure of compounded Avastin as outlined in the Step Therapy section.

Medicare Part B Sources:

• Medications/Drugs (Outpatient/Part B) https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-mp/medications-drugs-outpatient-partb.pdf
• Medicare Part B Step Therapy Programs: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-mp/medicare-part-b-step-therapy-programs.pdf

Additional Resources

• https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/125387lbl.pdf

MEDICAID

Note: This Medical Benefit Drug Policy does not apply to the states listed below; refer to the state-specific policy/guideline, if noted:

Other Pertinent Information

Eylea HD is limited to no more than 12 doses per year per eye, regardless of diagnosis. 

• Dosages and Administration:
  

  • Initial Phase: Monthly intravitreal injections for the first three months.
  • Maintenance Phase: Administered every 8 to 12 weeks depending on clinical response.

• Quantity Limits:

  • No more than 12 doses per year per eye 

Initial Approval Criteria

Approval requires:

• A documented diagnosis.
• Compliance with quantity limit of 12 doses per year per eye.

Continuation Criteria

• Continuation of therapy is contingent upon:
  • Documentation of a positive clinical response to treatment.
  • Adherence to the limit of 12 doses per year per eye.

Medicaid Sources:

• https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/ophthalmologic-vascular-endothelial-growth-factor-inhibitors-cs.pdf

Additional Resources

• Maximum Dosage and Frequency https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/maximum-dosage-policy-cs.pdf
• Macular Degeneration Treatment Procedures https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/macular-degeneration-treatment-procedures-cs.pdf

COMMERCIAL

Other Pertinent Information

• Eylea HD is classified as a non-preferred productunder certain step therapy programs.
  • Clinical rationale, including documented contraindications or intolerance to preferred therapies (e.g.,     compounded Avastin), is required for approval.
  • Therapy is restricted to FDA-approved indications and requires supporting documentation for off-label uses.

Quantity Limits:

• The administration of Eylea HD is restricted to no more than 12 doses per year per eye, regardless of the diagnosis or indication. 

Initial Approval Criteria

• Eylea HD therapy is approved when the diagnosis is confirmed and documented.
• The treatment plan must align with the following guidelines:
  • Administration Limit: No more than 12 doses per year per eye, regardless of diagnosis.
  • Initial approval is based on meeting medical necessity criteria and following the outlined dosing regimen.

• Continuation of Eylea HD therapy requires documentation of a positive clinical response to the treatment.
  • Examples of Positive Clinical Response:
    • Stabilization or improvement in vision (e.g., best corrected visual acuity [BCVA]).
    • Reduction in disease progression, such as reduced retinal thickness or new lesion development.
• Administration continues to be restricted to no more than 12 doses per year per eye.

Commercial Sources:

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/ophthalmologic-vegf-inhibitors.pdf?

Additional Resources:

• Macular Degeneration Treatment Procedures https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/macular-degeneration-treatment-procedures.pdf
• Maximum Dosage and Frequency https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/maximum-dosage-policy.pdf
• Medical Benefit Therapeutic Equivalent Medications - Excluded Drugs https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/medical-benefit-therapeutic-equivalent-excluded-drugs.pdf