AFLIBERCEPT-AYYH

Guidelines for Use

GUIDELINES FOR USE

INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)

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

1. You have ONE of the following:
1. Neovascular (wet) age-related macular degeneration (nAMD: a type of eye disease)
2. Macular edema following retinal vein occlusion (RVO: a type of eye condition)
3. Diabetic macular edema (DME: a type of eye condition caused by high blood sugar)
4. Diabetic retinopathy (DR: a type of eye condition caused by high blood sugar)
5. Retinopathy of prematurity (ROP: a type of eye condition in babies that are born early)
2. If you have neovascular (wet) age-related macular degeneration, approval also requires:
   1. You will NOT use Pavblu 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], Eylea [aflibercept])
3. If you have macular edema following retinal vein occlusion, approval also requires:
   1. You will NOT use Pavblu 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], Eylea [aflibercept])
   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)
4. If you have diabetic macular edema, approval also requires:
   1. You will NOT use Pavblu 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], Eylea [aflibercept])
5. 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)

Renewal Criteria

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

1. You have ONE of the following:
1. Neovascular (wet) age-related macular degeneration (nAMD: a type of eye disease)
2. Diabetic macular edema (DME: a type of eye condition caused by high blood sugar)
3. Diabetic retinopathy (DR: a type of eye condition caused by high blood sugar)
2. 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 Pavblu 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], Eylea [aflibercept])
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 Pavblu 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], Eylea [aflibercept])
4. If you have diabetic retinopathy, renewal also requires:
   1. You have maintenance or improvement of visual acuity (vision clarity or sharpness)