Eylea®

Drug - Eylea® (aflibercept) [Regeneron Pharmaceuticals, Inc.]

April 2020

Therapeutic area - Macular Degeneration Agents

Initial approval criteria

• Patient is 18 years or older AND
• Patient is free of ocular and/or peri-ocular infections AND
• Patient does not have active intraocular inflammation AND
• Eylea is prescribed by an ophthalmologist AND
• Therapy will not be used with other ophthalmic VEGF inhibitors AND
• Patient has a definitive diagnosis of one of the following:
  • Neovascular (Wet) Age-Related Macular Degeneration (AMD)
  • Macular Edema following Retinal Vein Occlusion (RVO)
  • Diabetic Macular Edema (DME)
  • Diabetic Retinopathy (DR)

Renewal criteria

• Patient continues to meet the criteria identified in section III AND
• Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following: endophthalmitis and retinal detachments; increase in intraocular pressure; arterial thromboembolic events AND
• Patient had a beneficial response to therapy AND
• Continued administration is necessary for the maintenance treatment of the condition

Quantity limits

• 2mg per eye every 28 days

Billing for Eylea

Eylea must be billed as a medical claim.

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411