Aetna: Beovu Payer Policy (Beta Access)

TABLE OF CONTENTS

• Medicare Part B
  
• Commercial

 MEDICARE PART B

Other Pertinent Information:

• All other indications will be assessed on an individual basis.
• Submissions for non-listed indications must include supporting evidence from Medicare-approved compendia:
  • National Comprehensive Cancer Network (NCCN)
  • Micromedex DrugDex
  • American Hospital Formulary Service-Drug Information (AHFS-DI)
  • Lexi-Drugs
  • Clinical Pharmacology

• Exclusion(s): All indications not specified as FDA-approved or supported by Medicare-approved compendia. 

Initial Approval Criteria

Authorization of 12 months may be granted for:

1. Neovascular (wet) age-related macular degeneration
2. Diabetic macular edema

Continuation Criteria

Authorization of 12 months may be granted when ALL of the following are met:

1. The member is currently receiving therapy with Beovu.
2. Beovu is being used to treat an approved indication (Section II).
3. The medication has been effective for treating the diagnosis or condition.

Resources:

1. https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/Beovu-3348-A-Aetna-MedB.pdf

COMMERCIAL

Other Pertinent Information

Beovu is considered medically necessary for neovascular AMD only after failure, contraindication, or intolerance to Avastin. 

• Quantity Limits:

  • 6 mg per injection at the approved dosing schedule:
    • Monthly injections initially (weeks 0, 4, and 8), followed by maintenance every 8-12 weeks.
• Exclusion(s):
  • All indications other than neovascular AMD are considered not medically necessary.

Initial Approval Criteria

Authorization for Beovu is considered medically necessary for 12 months when the following criteria are met:

1. Diagnosis of neovascular (wet) age-related macular degeneration (AMD).
2. Member has failed, has contraindications to, or is intolerant of Avastin (bevacizumab).

Continuation Criteria

Authorization for Beovu may be renewed for 12 months if:

1. The member has positive clinical response to therapy, such as:
   • Improvement or stabilization in visual acuity.
   • Reduction in disease activity

Resources:

• https://www.aetna.com/cpb/medical/data/700_799/0701.html