Quick Case Challenge
MR is a 72-year-old Latina woman with a history of type 2 diabetes for over 20 years. She lives in a rural area and is covered by a Medicare Advantage plan. Recently, she was diagnosed with diabetic macular edema (DME). The retinal specialist recommends starting treatment with an anti-VEGF agent. Her health plan requires step therapy with bevacizumab before approving any other anti-VEGF agents. However, the health plan is also reviewing its utilization management policy and exploring collaborative approaches with providers to reduce vision-related complications in high-risk populations.
References
- American Academy of Ophthalmology Preferred Practice Pattern Retina/Vitreous Committee: Stephen J. Kim, MD, Jennifer I. Lim, MD, FARVO, Steven T. Bailey, MD,3 Jaclyn L. Kovach, MD, FASRS4 G. Atma Vemulakonda, MD, Gui-shuang Ying, MD, PhD, Christina J. Flaxel, MD. Diabetic Retinopathy PPP 2024. https://www.aao.org/education/preferred-practice-pattern/diabetic-retinopathy-ppp.
- Diabetic Retinopathy Clinical Research Network; Wells JA, Glassman AR, Ayala AR, Jampol LM, Aiello LP, Antoszyk AN, Arnold-Bush B, Baker CW, Bressler NM, Browning DJ, Elman MJ, Ferris FL, Friedman SM, Melia M, Pieramici DJ, Sun JK, Beck RW. Aflibercept, bevacizumab, or ranibizumab for diabetic macular edema. N Engl J Med. 2015 Mar 26;372(13):1193-203.
- Lockhart CM, Barakat MR, Dunn JD, Richardson T, Bratcher T, Greene E, Kobernick M, Schneider D, Wigginton J. Transforming retinal disease management through diabetes care. J Manag Care Spec Pharm. 2025 Apr;31(4-a Suppl):S1-S11.
- Chaudhury AS, Ige M, Marwah S, et al. Race, Social Determinants of Health, and the Quality of Diabetic Eye Care. JAMA Ophthalmol. Sep 12 2024;