As previously communicated in a Partners in Health UpdateSM article, as of January 1, 2020, Avastin® and its biosimilars (i.e., Mvasi™, Zirabev™) are the preferred intravitreal vascular endothelial growth factor (VEGF) products for AmeriHealth members.* We will continue to cover the other intravitreal VEGF products, but they will be approved only for members who have demonstrated failure, contraindication, or intolerance to Avastin or an Avastin biosimilar.
Currently, there are six intravitreal VEGF products that treat ophthalmologic conditions such as neovascular (wet or exudative) advanced macular degeneration and diabetic macular edema:
- Avastin® (bevacizumab)
- Eylea® (aflibercept)
- Lucentis® (ranibizumab)
- Macugen® (pegaptanib)
- Mvasi™ (bevacizumab-awwb)
- Zirabev™ (bevacizumab-bvzr)
Updates to VEGF precertification requirements for ophthalmologic indications
Requests for intravitreal Avastin or its biosimilars do not require precertification approval from AmeriHealth.
All new requests for Eylea, Lucentis, or Macugen received on or after January 1, 2020, require precertification approval for all AmeriHealth members.
Members who have received Eylea, Lucentis, or Macugen in the past 12 months will continue to be approved to receive treatment with these drugs.
Learn more
Medical Policy #08.00.74m: Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and related biosimilars has been updated to reflect the new step therapy criteria.
These changes are reflected in updated precertification requirement lists, which are posted on the AmeriHealth New Jersey and AmeriHealth Pennsylvania websites.
*As additional biosimilars to Avastin receive approval from the U.S. Food and Drug Administration, these products will also be designated as preferred products for AmeriHealth members.