Aetna: Vabysmo Payer Policy (Beta Access)

TABLE OF CONTENTS

• Medicare Part B
  
• Commercial

 MEDICARE PART B

Note: Step therapy applies for Vabysmo as it is a non-preferred product.
Member must have:
Inadequate response or intolerable adverse event to bevacizumab (Avastin) and a secondary preferred product (e.g., Byooviz, Eylea, or Eylea HD), or Contraindication to preferred products

Other Pertinent Information

• Vabysmo is considered non-preferred and is only covered after meeting step therapy requirements.
• Requests for non-listed indicationsmust include supporting evidence from Medicare-approved compendia, such as:
  • National Comprehensive Cancer Network (NCCN)
  • Micromedex DrugDex
  • AHFS-DI
  • Lexi-Drugs

• Exclusion(s):
  • All other indications not listed above or supported by Medicare-approved compendia. 

Initial Approval Criteria

Authorization of 6 months may be granted for:

1. Neovascular (wet) age-related macular degeneration (AMD)
2. Diabetic macular edema (DME)
3. Macular edema following retinal vein occlusion (RVO)

Continuation Criteria

Authorization for 12 months may be granted if:

1. The member is currently receiving therapy with Vabysmo.
2. Vabysmo is being used to treat an approved indication listed above.
3. There is a positive clinical responseto therapy, such as:
   • Improvement or maintenance in best corrected visual acuity (BCVA), or
   • Reduction in the rate of vision decline or risk of severe vision loss.

Sources:

• https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/Vabysmo-5160-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

Other Pertinent Information

• Vabysmo is considered more costly than Avastin (bevacizumab) and other preferred VEGF inhibitors.
• Coverage is only approved when there is a failure, contraindication, or intolerance to the preferred products.

• Quantity Limits:

• Exclusion(s):
  • All other indications not listed as FDA-approved are considered not medically necessary. 

Initial Approval Criteria

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

1. The member has a diagnosis of one of the following conditions:
   • Neovascular (wet) age-related macular degeneration (AMD)
   • Diabetic macular edema (DME)
   • Diabetic retinopathy (DR)
   • Macular edema following retinal vein occlusion (RVO)
2. The member has failed, has a contraindication to, or is intolerant of Avastin (bevacizumab).

Continuation Criteria

Authorization for 12 months is considered medically necessary when:

1. The member is currently receiving therapy with Vabysmo.
2. Documentation of positive clinical responseis provided, such as:
   • Improvement or maintenance of best corrected visual acuity (BCVA).

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