Assessing variation in US payer coverage of anti-vascular endothelial growth factor therapies for the treatment of age-related macular degeneration, diabetic retinopathy, and diabetic macular edema.

Background: Timely anti-vascular endothelial growth factor (anti-VEGF) therapy is recommended to preserve vision in age-related macular degeneration (AMD), diabetic retinopathy (DR), and diabetic macular edema (DME). Coverage of anti-VEGF agents for the treatment of retinal diseases varies, resulting in administrative burdens for providers and treatment delays for patients.

Objective: To examine how US commercial and Medicare Advantage (MA) health plans cover anti-VEGF therapies for the treatment of retinal diseases using information from the Tufts Medical Center Specialty Drug Evidence and Coverage Database.

Methods: This descriptive study evaluated coverage of US Food and Drug Administration (FDA)-approved anti-VEGF drugs for AMD, DR, and DME current as of April 2024 using the Specialty Drug Evidence and Coverage Database from 18 of the largest US commercial health plans and MA offerings from a subset of 6 of these plans.

Results: Substantial variation exists in commercial coverage across FDA-approved anti-VEGF therapies for AMD, DR, and DME. Descriptive assessment showed that approximately 65% of commercial coverage decisions and approximately 52% of MA decisions included restrictions beyond the FDA label. Coverage decisions for originator products were more likely to include restrictions compared with those for biosimilar products. Step therapy protocols were found in up to 75% of plans but were variable by drug, with most requiring a first-line trial of bevacizumab. Evidence cited to support coverage restrictions was likewise variable.

Conclusions: Descriptive data show that US commercial and MA coverage and step therapy protocols vary substantially across health plans, which may potentially contribute to administrative burdens and treatment delays.