Due to the volume and high-dollar cost of anti-VEGF medications, many commercial, Medicare Advantage (MA) and Medicaid HMO plans may require prior authorizations (PA) for coverage. Each insurance carrier has unique policies, and they change frequently. Identifying these policies, monitoring updates and implementing internal workflows is an inherent part of the retina practice.
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Insurance payer policies may require a preferred drug therapy for intravitreal injections, typically a lower-cost drug (e.g. Avastin), and documented failed response before initiating a preferred drug (e.g. Eylea, Lucentis). This type of policy is called step therapy and can dramatically impact the prior authorization process and patient access to care.
Academy Step Therapy Resources
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