Effective January 1, 2020, Avastin® and its biosimilars (i.e., Mvasi™, Zirabev™) will be 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, will 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.
In October, AmeriHealth will send letters to affected providers to notify them of these changes.
Additional information about this change will be communicated in future Partners in Health UpdateSM articles, and our medical policy will be updated to reflect these new requirements.
These changes will also be reflected in updated precertification requirement lists, which will be posted to 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.