CurrentAetnaPolicy N/A

Lucentis_Byooviz_Cimerli_Precertification_Request

This document is an Aetna injectable medication precertification request form to obtain prior authorization for Lucentis (ranibizumab), Byooviz (ranibizumab-nuna), or Cimerli (ranibizumab-eqrn). It collects patient, prescriber, dispensing, product, diagnosis, and clinical response information required for precertification review.

Policy Summary

PayerAetna

PolicyLucentis_Byooviz_Cimerli_Precertification_Request

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete and submit this precertification request form with all required clinical documentation for Lucentis, Byooviz, or Cimerli; incomplete or illegible forms may delay review.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

3Ranibizumab products covered on form

5Diagnoses selectable

Policy overview and purpose

This is an Aetna injectable medication precertification request form for intravitreal ranibizumab products — Lucentis (ranibizumab), Byooviz (ranibizumab-nuna), and Cimerli (ranibizumab-eqrn). The two-page form collects administrative and clinical information to initiate a prior authorization review and must be completed and legible for precertification review.

The form collects patient demographics (name, DOB, contact information, weight/height, allergies), insurance details (member and group IDs, Medicare/Medicaid indicators), prescriber information (name, credentials, license, NPI, specialty, phone/fax), and dispensing/administration details (place of administration, administration CPT code, dispensing provider/pharmacy selection and contact information).

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Coverage stance and required documentation

Coverage stance: informational — this form facilitates Aetna's prior authorization review but does not by itself state specific coverage limits or criteria.

Scope: the form is intended for requests for Lucentis, Byooviz, or Cimerli and is used to collect documentation to support authorization decisions, including product/dose selection, diagnosis, prior response or intolerance to alternative therapies (e.g., Avastin), and evidence of clinical response for continuation.

Providers must complete and submit the form with all required clinical documentation; incomplete or illegible forms may delay review. For Medicare Advantage Part B members, providers are instructed to use the Medicare Request Form instead of this form.

For All Requests (required documentation)

Clinical documentation required for all requests; select diagnosis:

Select diagnosis

Diagnosis: Diabetic macular edema
Diagnosis: Diabetic retinopathy
Diagnosis: Macular edema following retinal vein occlusion
Diagnosis: Myopic choroidal neovascularization
Diagnosis: Neovascular (wet) age-related macular degeneration

Lucentis Requests Only

Additional clinical history required for Lucentis:

Lucentis additional history

Prior Avastin: Has the patient had an ineffective response, contraindication or intolerance to Avastin?
Yes/No checkbox
Prior biosimilar: Has the patient had an ineffective response, contraindication or intolerance to Byooviz OR Cimerli?
Yes/No checkbox

Byooviz and Cimerli Requests Only

Additional clinical history required for biosimilars:

Biosimilar additional history: Has the patient had an ineffective response, contraindication or intolerance to Avastin?

Yes/No checkbox

Continuation Requests

Clinical documentation required for continuation:

Continuation response: Has the patient demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in BCVA or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss)?

Yes/No checkbox

Actions, documentation, and submission instructions

Prior Authorization

Precertification required

Providers must complete and submit this precertification request form with all required clinical documentation for Lucentis, Byooviz, or Cimerli; incomplete or illegible forms may delay review.

Documentation Required

Clinical documentation for diagnosis and prior therapies

Providers must indicate primary and other ICD codes, selected diagnosis, prior response/intolerance to Avastin (and to Byooviz/Cimerli where applicable), and for continuation requests document positive clinical response (e.g., BCVA or visual field changes).

Primary and other ICD-10 diagnosis codes
Selected diagnosis (choose from listed diagnoses)
Prior response/intolerance to Avastin (and to Byooviz/Cimerli for Lucentis requests as applicable)
For continuation requests: documentation of positive clinical response (e.g., BCVA or visual field changes)

Billing Rule

Use Medicare request form for MA Part B

For Medicare Advantage Part B members, providers are instructed to use the Medicare Request Form instead of this form.

Documentation Required

Signature and attestation

Request must be signed by the requester; warning that knowingly providing false information is fraud and may result in penalties.

Warning: knowingly filing false information is a fraudulent insurance act and may result in criminal and civil penalties.

Prior Authorization

Aetna precertification contact

Submit requests or questions to Aetna Precertification Notification via phone or fax as listed below.

Phone: 1-866-752-7021 (TTY: 711)
Fax: 1-888-267-3277

Form purpose and workflow notes

Background: this two-page injectable medication precertification request form is designed to collect administrative and clinical information necessary to request precertification for intravitreal ranibizumab products, including the originator and biosimilars.

Typical data elements requested on the form include patient demographics and contact information; insurance identifiers and other coverage details; prescriber name, credentials, license/NPI and specialty; and dispensing/administration provider information (place of administration, CPT administration code, dispensing pharmacy/provider).

Clinical items captured include product selection (options for Lucentis, Byooviz, or Cimerli), dose and directions for use; primary and other ICD diagnosis codes; selection of one of the listed ophthalmic diagnoses; prior therapy history and responses (checkboxes for ineffective response, contraindication or intolerance to Avastin and, where applicable, to Byooviz or Cimerli); and for continuation requests documentation that the patient has demonstrated a positive clinical response (e.g., improvement or maintenance in BCVA or visual field).

The completed and signed request (signature required) is submitted to Aetna Precertification Notification (phone 1-866-752-7021, TTY 711; fax 1-888-267-3277). The form warns that knowingly providing false information is fraudulent and may result in penalties.