CurrentAetnaPolicy N/A

Eylea / Eylea HD and biosimilars injectable medication precertification request form

This document is Aetna's precertification request form and instructions for Eylea, Eylea HD, and specified aflibercept biosimilars for providers seeking authorization for initiation or continuation of therapy.

Policy Summary

PayerAetna

PolicyEylea / Eylea HD and biosimilars injectable medication precertification request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed precertification form including patient, prescriber, product, administration, ICD code, and required clinical documentation to request authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Page 1 of 2form length

Requires clinical documentationclinical info required

Phone/Fax providedcontact

Coverage and Authorization Criteria

Information required for authorization

Authorization is requested when the following information is provided on the form

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Form completion: All required patient, insurance, prescriber, dispensing, and product fields are completed

See sections A–F on form

Diagnosis selection: Selected diagnosis corresponds to one of the listed retinal/neovascular conditions (e.g., Diabetic Macular Edema, Diabetic Retinopathy, Macular Edema following Retinal Vein Occlusion, Neovascular (Wet) Age-Related Macular Degeneration, Retinopathy of Prematurity, or other specified diagnosis)

See section G on form

Prior therapy consideration: Document whether the patient had an ineffective response, contraindication, or intolerance to Avastin; document whether the patient had an ineffective response, contraindication, or intolerance to specified biosimilars (Byooviz or Cimerli) when asked

Form includes explicit checkboxes for prior Avastin and biosimilar response

Continuation response: For all continuation requests, document a positive clinical response to therapy (e.g., improvement or maintenance in best corrected visual acuity [BCVA] or visual field, or reduction in the rate of vision decline or risk of more severe vision loss)

Section G continuation requirements

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Precertification is required for Eylea, Eylea HD, Opuviz, Yesafili and listed biosimilars. Submit requests using this precertification form and contact Aetna Precertification Notification if needed.

Aetna Precertification Notification Phone: 1-866-752-7021 (TTY: 711)
Fax: 1-888-267-3277
For Medicare Advantage Part B: Use Medicare Request Form

Step Therapy

Prior Avastin / Biosimilar Consideration

The form asks whether the patient has had an ineffective response, contraindication, or intolerance to Avastin (and, where applicable, to Byooviz or Cimerli). Indicate Yes or No and provide supporting clinical documentation as required.

For Eylea, Opuviz, Yesafili: document Avastin response/contraindication/intolerance; also ask about Byooviz or Cimerli response where prompted.
For Eylea HD: document Avastin response/contraindication/intolerance and Byooviz or Cimerli response where prompted.

Documentation Required

Required Documentation on Form

Complete all required fields on the precertification form and include legible patient and prescriber information plus clinical details. The form requires patient demographics and contact info, prescriber details and licensure (including NPI and specialty), the requested product and dosing, diagnosis ICD code(s), and full clinical rationale including response to prior therapy and, for continuation requests, documentation of positive clinical response.

Patient information: name, DOB, address, phones, weight/height, allergies (Chunk 1).
Prescriber information: name, credentials, address, phone, fax, state license, NPI, DEA, specialty, office contact (Chunk 3).
Product and dosing: select product (Eylea, Eylea HD, Opuviz, Yesafili), dose and frequency (Chunk 5).
Diagnosis: primary and secondary ICD codes (Chunk 6).
Clinical information: select diagnosis indication, document prior therapy response/intolerance, and for continuation requests document demonstrated positive clinical response (Chunk 7,10).
Indicate whether this is start of treatment (include start date) or continuation (include date of last treatment) and provide requestor contact (Chunk 0).

Denial Risk

Fraud / Additional Information

Any person who knowingly submits materially false information or conceals material information to obtain authorization may be committing insurance fraud and is subject to criminal and civil penalties. Aetna may request additional information or clarification to evaluate the request.

Request must be signed and dated by the person completing the form (signature required).
Materially false statements or concealment of information may constitute a fraudulent insurance act with penalties.
The plan may request additional information or clarification if needed to evaluate requests.

Clinical Background

Aflibercept (branded as Eylea and Eylea HD) and named biosimilars (for example, Opuviz and Yesafili) are injectable intravitreal therapies used to treat retinal vascular and neovascular eye conditions. Typical indications listed on the form include diabetic macular edema, diabetic retinopathy, macular edema following retinal vein occlusion, neovascular (wet) age-related macular degeneration, and other retinal/neovascular diagnoses. The precertification form requires completion of diagnosis selection and supporting clinical information to document the indication for therapy.

The form requests specific product selection and clinical details: the requested product (Eylea, Eylea HD, Opuviz, Yesafili), primary ICD code(s), prior therapy history (including whether the patient had ineffective response, contraindication, or intolerance to Avastin), and for continuation requests documentation of positive clinical response (for example, improvement or maintenance in best corrected visual acuity or visual field, or reduction in the rate of vision decline) to support ongoing authorization.

Products and Clinical Definitions

Products covered

Trade name - EyleaEylea (aflibercept)

Trade name - Eylea HDEylea HD (aflibercept)

Biosimilar - OpuvizOpuviz (aflibercept-yszy)

Biosimilar - YesafiliYesafili (aflibercept-jbvf)

Positive clinical response — continuation criterion

DefinitionImprovement or maintenance in best corrected visual acuity (BCVA) or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss.

Documentation contextRequired for all continuation requests on the precertification form (Yes/No checkbox).

Use for authorization decisionA documented positive clinical response supports ongoing authorization for continuation of therapy.

OpenPayer

Eylea / Eylea HD and biosimilars injectable medication precertification request form

Coverage and Authorization Criteria

Administration and Billing Codes

Provider Actions and Documentation Requirements

Clinical Background

Products and Clinical Definitions