Anti-VEGF Medical Step Therapy Notice

Effective for dates of service on and after January 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon precertification initiation or renewal in addition to the current medical necessity review of all drugs noted below. Bevacizumab (under brand names: Avastin, Mvasi, and Zirabev) is preferred for the indication of wet age-related macular degeneration.

 

The clinical criteria below will be updated to include the requirement of a preferred agent effective

January 1, 2021.

 

Clinical Criteria	Status	Drug(s)	HCPCS Codes
ING-CC-0072	Preferred	Avastin	J9035, C9257
ING-CC-0072	Preferred	Mvasi	Q5107
ING-CC-0072	Preferred	Zirabev	Q5118
ING-CC-0072	Non-preferred	Eylea	J0178
ING-CC-0072	Non-preferred	Lucentis	J2778
ING-CC-0072	Non-preferred	Macugen	J2503
ING-CC-0072	Non-preferred	Beovu	J0179

 

The clinical criteria is publicly available on our website at https://mediproviders.anthem.com/nv.

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 1-844-396-2330.

 

 

ANV-NU-0162-20