Aetna: Byooviz Payer Policy (Beta Access)
TABLE OF CONTENTS
MEDICARE PART B
| HCPCS Code(s): | Q5124 |
| Precertification Required? | ✅ Yes (Click Here for Full Policy) |
| Step Therapy Required? | ✅ Yes (Click Here for Full Policy) |
| Provider Fax Form: | Byooviz Fax Form(✅ Available in SamaCare) |
| FDA Approved Indications: |
|
| Recommended Dosage: | Not Specified |
Note: Byooviz is considered preferred after a trial of bevacizumab (Avastin)
Other Pertinent Information
- Byooviz is listed as a Tier 2 Preferred Product after bevacizumab (Avastin).
- Submissions for non-listed indications require supporting evidence from Medicare-approved compendia (NCCN, Micromedex, AHFS-DI, Lexi-Drugs).
- Exclusion(s):
- All indications not listed as FDA-approved or supported by Medicare-approved compendia.
Initial Approval Criteria
Authorization for 12 months may be granted for the following conditions:
- Neovascular (wet) age-related macular degeneration (AMD)
- Macular edema following retinal vein occlusion (RVO)
- Myopic choroidal neovascularization (mCNV)
Continuation Criteria
Authorization for 12 months may be granted if:
- The member is currently receiving therapy with Byooviz.
- Byooviz is being used to treat an approved indication.
- The medication has been effective in treating the condition (e.g., improvement or maintenance of visual acuity).
Sources:
- https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/Lucentis-Byooviz-Cimerli-2508-A-Aetna-MedB.pdf
- https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/VEGF-Inhibitors-for-ocular-indications-1031-AMBST.pdf
COMMERCIAL
| HCPCS Code(s): | Q5124 |
| Precertification Required? | ✅ Yes (Click Here For Full Policy) |
| Step Therapy Required? | ✅ Yes (Click Here For Full Policy) |
| Provider Fax Form: | Byooviz Fax Form(✅ Available in SamaCare) |
| FDA Approved Indications: |
|
| Recommended Dosage: | Ranibizumab-nuna is available as Byooviz 10 mg/mL solution in a single-dose glass vial designed to provide 0.05 mL for intravitreal injection.
|
Other Pertinent Information
- Exclusion(s):
- All other indications not listed above are considered not medically necessary.
Initial Approval Criteria
Authorization is considered medically necessary for 12 months when the member meets the following:
- Diagnosis of one of the following:
- Neovascular (wet) age-related macular degeneration (AMD)
- Diabetic macular edema (DME)
- Diabetic retinopathy (DR)
- Macular edema following retinal vein occlusion (RVO)
- Myopic choroidal neovascularization (mCNV)
- Failure, contraindication, or intolerance to Avastin (bevacizumab).
Continuation Criteria
Authorization is considered medically necessary for 12 months if:
- The member is currently receiving therapy with Byooviz.
- Documentation of positive clinical response to therapy (e.g., improvement or maintenance in best corrected visual acuity [BCVA]).
Sources:
⚠️ Disclaimer: This article is a policy summary and does not guarantee coverage or approval.
Policies may vary based on plan, payer-specific rules, state or regional requirements, benefit structure, formulary placement, and patient-specific considerations like diagnosis or clinical history. Always review the full policy and confirm details directly with the payer to ensure compliance.
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