BlueCross BlueShield of Tennessee Medical Policy Manual

Aflibercept

NDC CODE(S)

61755-0005-XX Eylea 2 MG/0.05ML SOLN (REGENERON PHARMACEUTICALS)

DESCRIPTION

Aflibercept is a recombinant fusion protein consisting of portions of human VEGF receptors 1 and 2 extracellular domains fused to the Fc portion of human IgG1 formulated as an iso-osmotic solution for intravitreal administration. Vascular endothelial growth factor-A (VEGF-A) and placental growth factor (PlGF) are members of the VEGF family of angiogenic factors that can act as mitogenic, chemotactic, and vascular permeability factors for endothelial cells.

VEGF acts via two receptor tyrosine kinases, VEGFR-1 and VEGFR-2, present on the surface of endothelial cells. PlGF binds only to VEGFR-1, which is also present on the surface of leucocytes. Activation of these receptors by VEGF-A can result in neovascularization and vascular permeability.  Aflibercept is a dimeric glycoprotein which acts as a soluble decoy receptor that binds VEGF-A and PlGF, and thereby can inhibit the binding and activation of these cognate VEGF receptors.

POLICY

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

*NOTE:  Treatment naïve (new to therapy – commercial line of business only)

Treatment with Aflibercept may be initiated if the patient has a documented contraindication or severe intolerance to BOTH bevacizumab AND/OR ranibizumab.

**Optical Coherence Tomography (OCT) and VA testing must be completed within 56 days after the last injection of bevacizumab and/or ranibizumab when requesting Aflibercept. We recommend specialists ensure patients have received a proper exam of their eyes by a qualified provider within the appropriate time frames to ensure individuals BCVA is optimal.

RENEWAL CRITERIA

INDICATION(S)

DOSAGE & ADMINISTRATION

AMD

Initiation:

2 mg intravitreally once every 4 weeks (monthly) per affected

eye for the first 3 months

Maintenance:

2 mg once every 8 weeks (2 months) per affected eye;  however Aflibercept may be dosed as frequently as 2 mg every 4 weeks (monthly)

Additional efficacy was not demonstrated in most patients when Aflibercept was dosed every 4 weeks compared to every 8 weeks. Some patients may need every 4 week (monthly) dosing after the first 12 weeks (3 months).

Macular Edema following RVO

2 mg intravitreally once every 4 weeks (monthly) per affected eye

Diabetic macular edema and diabetic retinopathy in individuals with diabetic macular edema

Initiation:

2 mg intravitreally once every 4 weeks (monthly) per eye for the first 5 injections

Maintenance:

2 mg once every 8 weeks (2 months); however Aflibercept may be dosed as frequently as 2 mg every 4 weeks (monthly)

Additional efficacy was not demonstrated in most patients when Aflibercept was dosed every 4 weeks compared to every 8 weeks. Some patients may need every 4 week (monthly) dosing after the first 20 weeks (5 months).

LENGTH OF AUTHORIZATION

Coverage will be provided annually and may be renewed.

Click here to view DOSAGE LIMITS

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.

IMPORTANT REMINDER

We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION 

For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).

No controlled studies were found in the published literature that validates the use of aflibercept for the treatment of other conditions or diseases.

SOURCES

Lexicomp Online. (2016). AHFS DI. Aflibercept. Retrieved December 12, 2016 from Lexicomp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Evaluations. (2016, August). Aflibercept. Retrieved December 12, 2016 from MICROMEDEX Healthcare Series.

U. S. Food and Drug Administration. (2016, October). Center for Drug Evaluation and Research. Eylea® (aflibercept) injection. Retrieved December 12, 2016 from http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/125387s052lbl.pdf.

Nguyen QD, Brown DM, Marcus DM, et al. Ranibizumab for diabetic macular edema: results from 2 phase III randomized trials: RISE and RIDE. Ophthalmology 2012;119:789–801. doi.org/10.1016/j.ophtha.2011.12.039.

Wells JA, Glassman AR, Ayala AR, et al. Aflibercept, Bevacizumab, or Ranibizumab for Diabetic Macular Edema: Two-Year Results from a Comparative Effectiveness Randomized Clinical Trial. Ophthalmology 2016;123 (6):1351-9. doi.org/10.1016/j.ophtha.2016.02.022.

ORIGINAL EFFECTIVE DATE:  12/1/2016

MOST RECENT REVIEW DATE:  2/16/2018

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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.

 

 

DOSAGE LIMITS

Maximum billable units per dose and over time by indication as a Medical Benefit

Diagnosis

MU for Initial Dosing

MU for Maintenance Dosing

Neovascular age-related macular degeneration (AMD)

4 units every 28 days x 3 doses

4 units every 28-56 days

Macular edema following retinal vein occlusion (RVO)

4 units every 28 days

4 units every 28 days

Diabetic Macular Edema (DME)/ Diabetic retinopathy (DR) in DME

4 units every 28 days x 5 doses

4 units every 28-56 days

  (Max units are based on administration to both eyes)