Providers

New UHC Prior Authorization Requirements for Retina Injectables

The SamaCare Team

The SamaCare Team

United Healthcare released a medical benefit specialty drug update in October, adding new prior authorization requirements for specialty drugs that took effect January 1, 2021. Among these, UHC added step therapy requirements for Vascular Endothelial Growth Factor Drug Class (VEGF), and prior authorization requirements for non-preferred drugs including Beovu, Eylea, Lucentis, and Macugen to Commercial, Medicare Advantage, and Community Plans. 


This class of drugs is used to treat age related macular degeneration (AMD) and diabetic retinopathy. Both are common conditions: 

  • AMD is the leading cause of vision loss in people over 60. According to the National Eye Institute, 3 million Americans suffered from AMD in 2020. 
  • ⅓ of adults over 40 are impacted by diabetic retinopathy. The CDC estimates 4.2 million adults have DR and 655,000 have vision-threatening DR.


As such, these new requirements are already notably impacting the number of prior authorizations retina practices have to submit in a given month. When we compared prior authorizations data through the SamaCare system from January 2020 to January 2021, there was a 26% increase in the average number of authorizations per practice, driven by the increase in new PAs required.

For practices who do not streamline the PA process with SamaCare, this change from a single payer translates to ~3 additional hours of work per week for each practice.


What can retina practices do to help mitigate the additional time required to submit these prior authorizations? For practices already using SamaCare, it is possible to submit prior authorizations for VEGF drugs from our portal across all payers. For practices not using SamaCare, more information on UHC’s ophthalmologic policy for VEGF inhibitor coverage can be found here


If you are interested in learning more about implementing SamaCare for your practice, please request a demo on our website or reach out to our practice growth team: join@samacare.com.

Providers

New UHC Prior Authorization Requirements for Retina Injectables

The SamaCare Team

The SamaCare Team

United Healthcare released a medical benefit specialty drug update in October, adding new prior authorization requirements for specialty drugs that took effect January 1, 2021. Among these, UHC added step therapy requirements for Vascular Endothelial Growth Factor Drug Class (VEGF), and prior authorization requirements for non-preferred drugs including Beovu, Eylea, Lucentis, and Macugen to Commercial, Medicare Advantage, and Community Plans. 


This class of drugs is used to treat age related macular degeneration (AMD) and diabetic retinopathy. Both are common conditions: 

  • AMD is the leading cause of vision loss in people over 60. According to the National Eye Institute, 3 million Americans suffered from AMD in 2020. 
  • ⅓ of adults over 40 are impacted by diabetic retinopathy. The CDC estimates 4.2 million adults have DR and 655,000 have vision-threatening DR.


As such, these new requirements are already notably impacting the number of prior authorizations retina practices have to submit in a given month. When we compared prior authorizations data through the SamaCare system from January 2020 to January 2021, there was a 26% increase in the average number of authorizations per practice, driven by the increase in new PAs required.

For practices who do not streamline the PA process with SamaCare, this change from a single payer translates to ~3 additional hours of work per week for each practice.


What can retina practices do to help mitigate the additional time required to submit these prior authorizations? For practices already using SamaCare, it is possible to submit prior authorizations for VEGF drugs from our portal across all payers. For practices not using SamaCare, more information on UHC’s ophthalmologic policy for VEGF inhibitor coverage can be found here


If you are interested in learning more about implementing SamaCare for your practice, please request a demo on our website or reach out to our practice growth team: join@samacare.com.