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
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.