United Healthcare: Avastin Payer Policy

Created by Zoe Stanton, Modified on Thu, 16 Jan at 5:23 PM by C. Denise Burrell

United Healthcare: Avastin Payer Policy (Testing)

TABLE OF CONTENTS

United Healthcare: Avastin Payer Policy (Testing)

MEDICARE PART B

HCPCS Code(s):	J9035, C9257
Precertification Required?	Yes (Click Here For Full Policy)
Step Therapy Required?	Yes (Click Here For Full Policy)
Provider Fax Form:	Yes (✅ Available in SamaCare) Though this form is available in SamaCare, UHC may not accept faxed submissions. Instead, practices are encouraged to use the payer portal, which can be accessed directly through SamaCare!
FDA Approved Indications:	Neovascular (Wet) Age-Related Macular Degeneration (nAMD) Diabetic Macular Edema (DME) Diabetic Retinopathy (DR) Macular Edema following Retinal Vein Occlusion (RVO) Choroidal Neovascularization secondary to Pathologic Myopia Neovascular Glaucoma
Recommended Dosage:	Not Specified - Maximum Dosage & Frequency

Note: Coverage applies to UnitedHealthcare Medicare Advantage plans under the Medicare Part B Step Therapy Programs.

Non-Employer Group Medicare Advantage

Erickson Advantage® plans: H5652-001 through H5652-008
UnitedHealthcare Medicare Direct (Private Fee-For-Service, PFFS): H5435-001, H5435- 024
Certain UnitedHealthcare Dual Complete and Dual Choice plans:
- Arizona: H0321-004
- District of Columbia: H2228-045, H2406-053, H2406-099, H7464-010
- Florida: H2509-001
- Minnesota: H0845-001, H7778-001, H7778-002
- New Jersey: H3113-005
- New York: H3387-013
- Tennessee: H0251-004
- Virginia: H7464-005, H7464-007
UnitedHealthcare Connected plans(Medicare-Medicaid)
- Massachusetts: H9239-001
- Ohio: H2531-001
- Texas: H7833-001
UnitedHealthcare Senior Care Options in Massachusetts: H2226-001, H2226-003

Employer Group Medicare Advantage

All Group HMO plans
Select Group PPO plans:
- Bristol-Myers Squibb: H2001-869
- Johnson & Johnson: H2001-869
- United Auto Workers (UAW) Trust: H2001-870
- U.S. Government of the Virgin Islands (USGVI): H2001-859, H2001-868
- Verizon: H2001-869

Avastin is listed as a preferred product within the intravitreal vascular endothelial growth factor (VEGF) inhibitor class.

Non-preferred products may require:
- A trial of at least three consecutive doses given monthly of Avastin resulting in minimal clinical response, or
Documentation of intolerance, contraindication, or adverse events with Avastin.

Other Pertinent Information:

Avastin is recognized as the cost-effective first-line therapy within its class.
Licensed compounding pharmacies must follow strict guidelines for sterile preparation and storage.

Dosage and Administration:

Typical dosing ranges from 6.2 mcg to 2.5 mg per injection, prepared by licensed compounding pharmacies compliant with USP Chapter 797 standards.

Quantity Limits:

Limited to 12 doses per year per eye, regardless of diagnosis.

Initial Approval Criteria

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

Continuation Criteria

Documentation of positive clinical response to Avastin, such as stabilization or improvement in disease symptoms or progression.

Medicare Part B Sources:

Additional Resources

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

MEDICAID

HCPCS Code(s):	J9035, C9257
Precertification Required?	Yes (Click Here for Full Policy)
Step Therapy Required?	Yes (Click Here for Full Policy)
Provider Fax Form:	Yes (✅ Available in SamaCare) Though this form is available in SamaCare, UHC may not accept faxed submissions. Instead, practices are encouraged to use the payer portal, which can be accessed directly through SamaCare!
FDA Approved Indications:	Choroidal neovascularization secondary to pathologic myopia, angioid streaks/pseudoxanthoma elasticum, or ocular histoplasmosis syndrome (OHS). Diabetic macular edema (DME). Macular edema secondary to branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO). Neovascular age-related macular degeneration (nAMD). Neovascular glaucoma. Neovascularization of the iris (NVI) (rubeosis iridis). Proliferative diabetic retinopathy. Type I Retinopathy of Prematurity (ROP).
Recommended Dosage:	Not Specified - Maximum Dosage & Frequency

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

State	Policy/Guide Line
Indiana	Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Indiana Only)
Kansas	Refer to the state’s Medicaid clinical policy
Louisiana	Not Specified
North Carolina	Not Specified
Ohio	Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Ohio Only)
Pennsylvania	Refer to the state’s Medicaid clinical policy

Other Pertinent Information

Licensed compounding pharmacies must ensure adherence to strict guidelines for the preparation, transportation, and storage of sterile products.

Dosages and Administration:

Avastin is supplied in sterile vials containing a solution of 25 mg/mL.

Intravitreal administration doses range from 6.2 mcg to 2.5 mg, prepared by licensed compounding pharmacies compliant with USP Chapter 797 standards.

Quantity Limits:

Limited to no more than 12 doses per year per eye, regardless of diagnosis.

Initial Approval Criteria

A documented diagnosis meeting the FDA-approved indications.
Compliance with specified quantity limits.

Continuation Criteria

Documentation of positive clinical response to treatment, including stabilization or improvement in disease progression.

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

COMMERCIAL

HCPCS Code(s):	J9035, C9257
Precertification Required?	Yes (Click Here For Full Policy)
Step Therapy Required?	Yes (Click Here For Full Policy)
Provider Fax Form:	Yes (✅ Available in SamaCare) Though this form is available in SamaCare, UHC may not accept faxed submissions. Instead, practices are encouraged to use the payer portal, which can be accessed directly through SamaCare!
FDA Approved Indications:	Diabetic Macular Edema (DME) Diabetic Retinopathy (DR) Neovascular (Wet) Age-Related Macular Degeneration (nAMD) Choroidal neovascularization secondary to pathologic myopia, angioid streaks/pseudoxanthoma elasticum, or ocular histoplasmosis syndrome (OHS). Diabetic macular edema (DME). Macular edema secondary to branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO). Neovascular age-related macular degeneration (nAMD). Neovascular glaucoma. Neovascularization of the iris (NVI) (rubeosis iridis). Proliferative diabetic retinopathy. Type I Retinopathy of Prematurity (ROP).
Recommended Dosage:	Not Specified - Maximum Dosage & Frequency

Note: Coverage is provided under UnitedHealthcare Commercial plans, contingent upon the criteria outlined in the General Requirements and Diagnosis-Specific Requirements sections.

Other Pertinent Information

Adherence to the United States Pharmacopeia (USP) Chapter 797 standards for compounding, transportation, and storage of sterile products is mandatory.

Quantity Limits:

Administration of intravitreal Avastin is limited to no more than 12 doses per year per eye, regardless of the diagnosis.

Dosage and Administration

Avastin doses range from 6.2 mcg to 2.5 mg per injection, prepared by compounding pharmacies compliant with USP Chapter 797 standards for sterile product preparation
Initial Approval Criteria
Approval requires:
A documented diagnosis of one of the listed indications.
Compliance with the quantity limit of 12 doses per year per eye.
Continuation Criteria
Documentation of a positive clinical response to Avastin, including stabilization or improvement in disease progression.
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
content/dam/provider/docs/public/policies/comm-medical-drug/medical-benefit-therapeutic-equivalent-excluded-drugs.pdf

⚠️ Disclaimer: This article is a policy summary and does not guarantee coverage or approval. Policies may vary based on plan, payer-specific rules, state or regional requirements, benefit structure, formulary placement, and patient-specific considerations like diagnosis or clinical history. Always review the full policy and confirm details directly with the payer to ensure compliance.

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United Healthcare: Avastin Payer Policy

United Healthcare: Avastin Payer Policy (Testing)

MEDICARE PART B

Other Pertinent Information:

Dosage and Administration:

Quantity Limits:

Initial Approval Criteria

Continuation Criteria

Medicare Part B Sources:

MEDICAID

Other Pertinent Information

Dosages and Administration:

Avastin is supplied in sterile vials containing a solution of 25 mg/mL.

Intravitreal administration doses range from 6.2 mcg to 2.5 mg, prepared by licensed compounding pharmacies compliant with USP Chapter 797 standards.

Quantity Limits:

Limited to no more than 12 doses per year per eye, regardless of diagnosis.

Initial Approval Criteria

Medicaid Sources:

COMMERCIAL

Other Pertinent Information

Initial Approval Criteria

Continuation Criteria

Commercial Sources: