United Healthcare: Lucentis Payer Policy

Created by Zoe Stanton, Modified on Mon, 6 Jan at 3:30 PM by C. Denise Burrell

United Healthcare: Lucentis Payer Policy (Testing)

TABLE OF CONTENTS

United Healthcare: Lucentis Payer Policy (Testing)
- TABLE OF CONTENTS
  - MEDICARE PART B
  - COMMERCIAL

MEDICARE PART B

HCPCS Code(s):	J2778
Precertification Required?	✅ Yes (Click Here for Full Policy)
Step Therapy Required?	✅ Yes (Click Here for Full Policy)
Provider Fax Form:	Lucentis Fax Form Here (✅ Available in SamaCare)
FDA Approved Indications:	Lucentis (ranibizumab) is proven and medically necessary for the treatment of: Choroidal neovascularization secondary to pathologic myopia, angioid streaks/pseudoxanthoma elasticum, or ocular histoplasmosis syndrome (OHS) Diabetic macular edema (DME) Diabetic retinopathy (DR) Macular edema secondary to branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) Neovascular age-related macular degeneration (nAMD)
Recommended Dosage:

Note:

Initial Approval Criteria:

Step therapy requirements
Both of the following: Trial of at least 3 consecutive doses given monthly, resulting in minimal clinical response to compounded Avastin (bevacizumab); and a history of use of Eylea, resulting in minimal clinical response to therapy or History of contraindication, intolerance, or adverse event(s) to compounded Avastin (bevacizumab) and Eylea; or Continuation of prior therapy within the past 365 days.

Non-preferred product step therapy requirements:
History of use of Eylea, resulting in minimal clinical response to therapy; or History of contraindication or adverse event(s) to Eylea; or Continuation of prior therapy within the past 365 days.

COMMERCIAL

HCPCS Code(s):
Precertification Required?	✅ Yes (Click Here For Full Policy)
Step Therapy Required?	✅ Yes (Click Here For Full Policy)
Provider Fax Form:	[Link to Fax Form] (✅ Available in SamaCare)
FDA Approved Indications:
Recommended Dosage:

⚠️ 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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