Anthem: Beovu Payer Policy (Beta Access)

Note: 
Beovu is non-preferred.
Member must have trial and inadequate response or intolerance to one preferred agent.
Preferred agents include:
Avastin (bevacizumab)Byooviz (ranibizumab-nuna)Cimerli (ranibizumab-cqrn) Eylea (aflibercept).

Other Pertinent Information

• Quantity Limits:

  • 6 mg per eye, each eye may be treated as frequently as every 8 weeks. 

• Exclusion(s):
  • All other indications not listed above are considered not medically necessary.

Initial Approval Criteria

Authorization for 12 months is considered medically necessary when:

1. The member has a diagnosis of:
   • Neovascular (wet) age-related macular degeneration (AMD), or
   • Diabetic macular edema (DME), including DME with diabetic retinopathy of any severity.

Override Criteria

Beovu, may approve the following for initiation of therapy: 

I. Age-related macular degeneration: One 6 mg dose per eye monthly for the first three (3) doses; OR 

II. Diabetic macular edema (DME): One 6 mg dose per eye every six weeks for the first five (5) doses.

Continuation Criteria

Authorization for 12 months is considered medically necessary when:

1. The member is currently receiving therapy with Beovu.
2. There is documentation of positive clinical response to therapy.

Sources:

https://www.anthem.com/ms/pharmacyinformation/VEGF.pdf

Additonal Resources

Medical Specialty Precertification Drug List: https://file.anthem.com/06347MUPENABS.pdf

Medical Step Therapy Drug List: https://file.anthem.com/A02605ANPENABS.pdf

Site of Care Drug List: https://file.anthem.com/06346MUPENABS.pdf