Aetna: Susvimo Payer Policy (Beta Access)

TABLE OF CONTENTS

• Medicare Part B
  
• Commercial

 MEDICARE PART B

Note: Susvimo must be used in conjunction with the Susvimo ocular implant.

Initial Approval Criteria

Authorization of 12 months may be granted for treatment of neovascular (wet) age-related macular degeneration when the following criteria are met:

1. The member has a diagnosis of neovascular (wet) age-related macular degeneration.
2. The member has previously responded (within the last 6 months) to at least two intravitreal injections of a VEGF inhibitor (e.g., Avastin, Eylea).
3. Susvimo must be used with the Susvimo ocular implant.

Continuation Criteria

Authorization for 12 months may be granted if:

1. The member is currently receiving therapy with Susvimo.
2. Susvimo is being used to treat an approved indication.The medication has been effective for treating the diagnosis or condition.

Sources: 

https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/Susvimo-5046-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

• Susvimo must be used with the Susvimo ocular implant.
• Susvimo is considered more costly than Avastin and is only approved when there is a contraindication, intolerance, or failure of Avastin.

• 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 following criteria are met:

1. The member has a diagnosis of neovascular (wet) age-related macular degeneration (AMD).
2. The member has failed, has a contraindication to, or is intolerant of bevacizumab (Avastin).
3. Susvimo is being used with the Susvimo ocular implant.

Continuation Criteria:

Authorization is considered medically necessary for 12 months if:

1. The member is currently receiving therapy with Susvimo.
2. There is documentation of positive clinical responseto therapy, such as:
   • Improvement or maintenance of best corrected visual acuity (BCVA).

Sources:

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