​As previously communicated in a Partners in Health Update^SM 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. There are many brands of VEGF antagonists on the market for the treatment of vascular diseases of the eye, such as Beovu^®, Eylea^®, Lucentis^®, Macugen^®, and related biosimilars, but no reliable evidence of the superiority of any one brand of VEGF antagonists compared to other brands. Additionally, this article provides clarification regarding the coverage of samples administered by professional providers.

Coverage criteria

For individuals who meet the medical necessity criteria, use of non-preferred products (which include Beovu, Eylea, Lucentis, Macugen, and related biosimilars) is considered medically necessary and, therefore, covered in either the following instances: 

• The individual has a documented contraindication or documented non-response to Avastin and its related biosimilars.
• The non-preferred product was initiated prior to January 1, 2020, and the individual is currently receiving the product for vascular diseases of the eye.

The use of non-preferred products that do not meet either of these instances is considered not medically necessary and, therefore, not covered.

For individuals receiving their first course of VEGF antagonists, use of non-preferred products (which include, but are not limited to, Beovu, Eylea, Lucentis, Macugen, and related biosimilars), is considered not medically necessary and, therefore, not covered, with the following exceptions because more cost-effective alternatives are available:

• The individual has a documented contraindication or documented non-response to Avastin and its related biosimilars.
• The non-preferred product was initiated prior to January 1, 2020, and the individual is currently receiving the product for vascular diseases of the eye.

Please note: Use of non-preferred product samples administered by professional providers does NOT meet coverage criteria for use of non-preferred products (which include Beovu, Eylea, Lucentis, Macugen, and related biosimilars).

Additional clinical information demonstrating medical necessity of the desired medication must be submitted by the requesting prescriber for review.

Learn more

For more information, please refer to Medical Policy #08.00.74n: Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and related biosimilars.

These changes are reflected in updated precertification requirement lists, which are posted on the AmeriHealth New Jersey and AmeriHealth Pennsylvania websites.