AFLIBERCEPT-EYLEA HD

Guidelines for Use

GUIDELINES FOR USE

INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)

Our guideline named AFLIBERCEPT-EYLEA HD requires the following rule(s) be met for approval:

1. You have ONE of the following:
1. Diabetic retinopathy (DR: a type of eye condition caused by high blood sugar)
2. Diabetic macular edema (DME: a type of eye condition caused by high blood sugar)
3. Neovascular (wet) age-related macular degeneration (nAMD: a type of eye disease)
2. If you have macular edema following retinal vein occlusion, approval also requires:
   1. You will NOT use Eylea HD concurrently (at the same time) with other intravitreal (into the eye) vascular endothelial growth factor (VEGF) inhibitors (such as, Lucentis [ranibizumab], Susvimo [ranibizumab], Beovu [brolucizumab-dbll])
   2. You have tried or have a contraindication to (harmful for you to use) ONE of the following preferred medications: Cimerli (ranibizumab-eqrn) or Byooviz (ranibizumab-nuna)
3. If you have diabetic retinopathy, approval also requires:
   1. You have tried or have a contraindication to (harmful for you to use) ONE of the following preferred medications: Cimerli (ranibizumab-eqrn) or Byooviz (ranibizumab-nuna)
4. If you have diabetic macular edema, approval also requires:
   1. You will NOT use Eylea concurrently (at the same time) with other intravitreal (into the eye) vascular endothelial growth factor (VEGF) inhibitors (such as, Lucentis [ranibizumab], Susvimo [ranibizumab], Beovu [brolucizumab-dbll])

RENEWAL CRITERIA

Our guideline named AFLIBERCEPT-EYLEA HD requires the following rule(s) be met for renewal:

1. You have ONE of the following:
1. Diabetic retinopathy (DR: a type of eye condition caused by high blood sugar)
2. Diabetic macular edema (DME: a type of eye condition caused by high blood sugar)
3. Neovascular (wet) age-related macular degeneration (nAMD: a type of eye disease)
2. If you have diabetic retinopathy, renewal also requires:
   1. You have maintenance or improvement of visual acuity (vision clarity or sharpness)
3. If you have diabetic macular edema, renewal also requires:
   1. You have maintenance or improvement of visual acuity (vision clarity or sharpness)
   2. You will NOT use Eylea concurrently (at the same time) with other intravitreal (into the eye) vascular endothelial growth factor (VEGF) inhibitors (such as Lucentis [ranibizumab], Susvimo [ranibizumab], Beovu [brolucizumab-dbll])
4. If you have neovascular (wet) age-related macular degeneration, renewal also requires:
   1. You have maintenance or improvement of visual acuity (vision clarity or sharpness)
   2. You will NOT use Eylea concurrently (at the same time) with other intravitreal (into the eye) vascular endothelial growth factor (VEGF) inhibitors (such as Lucentis [ranibizumab], Susvimo [ranibizumab], Beovu [brolucizumab-dbll])