CurrentAetnaPolicy N/A

Eylea-Eylea HD ® and Biosimilars Injectable Medication Precertification Request

Aetna precertification request form to collect patient, prescriber, dispensing, product, diagnosis and clinical information required to request prior authorization for Eylea, Eylea HD and listed biosimilars (Opuviz, Yesafili). It governs submission content and required clinical documentation for start or continuation of therapy.

Policy Summary

PayerAetna

PolicyEylea-Eylea HD ® and Biosimilars Injectable Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must submit a completed precertification request form with all required fields and supporting clinical documentation to Aetna Precertification Notification via phone 1-866-752-7021 or fax 1-888-267-3277; Medicare Advantage Part B requests must use the Medicare request form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

4Products listed

6Diagnosis options

2Comparators referenced

Policy overview and scope

This is an Aetna precertification request form used to collect clinical and administrative information to allow payer review for medical necessity and to process prior authorization for injectable ophthalmic aflibercept products and their biosimilars, including Eylea (aflibercept), Eylea HD (aflibercept), Opuviz (aflibercept-yszy), and Yesafili (aflibercept-jbvf).

Submission and clinical requirements

General submission and clinical requirement overview

Precertification requests must include all required fields and documentation; clinical criteria differ for Eylea/Eylea HD and biosimilars:

ALL of the following

All fields on the precertification request form must be completed and legible for review.
Request type must be indicated: Start of treatment (include start date) or Continuation of therapy (include date of last treatment).
Submitter must provide patient demographic information including DOB, weight, height, allergies and contact information.
Submitter must provide insurance information including Aetna Member ID, group number and other coverage details, Medicare/Medicaid status and IDs if applicable.
Prescriber information must be provided including name, credentials, address, phone, fax, state license number, NPI, DEA, specialty and office contact.
Dispensing provider and place of administration must be specified (self, physician office, outpatient infusion center, home infusion, etc.) and administration CPT code(s) if applicable.
Product requested must be specified: Eylea (aflibercept), Eylea HD (aflibercept), Opuviz (aflibercept-yszy), Yesafili (aflibercept-jbvf); dose and frequency must be provided.
Primary and any secondary ICD codes must be provided (diagnosis information).
Clinical diagnosis selection required from list (Diabetic Macular Edema, Diabetic Retinopathy, Macular Edema Following Retinal Vein Occlusion, Neovascular (Wet) Age-Related Macular Degeneration, Retinopathy of Prematurity, Other).
Eylea / biosimilars disease-specific intolerance/response requirement
- For Eylea, Opuviz or Yesafili requests: indicate whether patient had an ineffective response, contraindication or intolerance to Avastin.
- For Eylea, Opuviz or Yesafili requests: indicate whether patient had an ineffective response, contraindication or intolerance to Byooviz OR Cimerli.
For Eylea HD requests: indicate whether patient had an ineffective response, contraindication or intolerance to Avastin and to Byooviz OR Cimerli.
For all continuation requests: provide documentation that patient demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in best corrected visual acuity [BCVA] or visual field, or reduction in rate of vision decline or risk of more severe vision loss).
Precertification may require additional information or clarification upon request by the plan.

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title": "General submission and clinical requirement overview

Required provider actions and documentation

Prior Authorization

Precertification submission required

Submit a completed precertification request form with all required fields and supporting clinical documentation to Aetna Precertification Notification. Use the Aetna phone or fax contact for submission. For Medicare Advantage Part B requests, use the Medicare request form.

Phone: 1-866-752-7021 (TTY: 711)
Fax: 1-888-267-3277
Medicare Advantage Part B requests must use the Medicare request form

Documentation Required

Clinical documentation required for biosimilars and Eylea products

Provide complete clinical documentation including the diagnosis (select primary ICD code), documentation of prior ineffective response, contraindication, or intolerance to Avastin (and to Byooviz OR Cimerli where requested for Eylea, Opuviz or Yesafili and required for Eylea HD), the requested product dose and frequency, and for continuation requests documentation that the patient demonstrated a positive clinical response to therapy (for example, improvement or maintenance in BCVA or visual field).

Billing Rule

Provide administration CPT codes when applicable

If administration occurs in a facility or office setting, supply the applicable administration CPT code(s) on the precertification form (Administration code(s) (CPT) field is provided).

Include administration CPT code(s) on the submission form