Anthem: Byooviz Payer Policy (Beta Access)

Note: : When an intravitreal VEGF antagonist is deemed approvable based on the clinical criteria above, the benefit plan may have additional criteria requiring the use of a preferred1 agent or agent.

Other Pertinent Information

Byooviz is an FDA-approved biosimilar to Lucentis.

• While Byooviz is not FDA-approved for diabetic macular edema (DME) or diabetic retinopathy (DR), efficacy may be extrapolated based on biosimilarity.

• Quantity Limits:

  • 0.5 mg per eye
  • Each eye may be treated as frequently as every 4 weeks.

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

Initial Approval Criteria

Authorization may be approved for 12 months when the member has a diagnosis of:

1. Neovascular (wet) age-related macular degeneration (AMD)
2. Macular edema following branch or central retinal vein occlusion (RVO)
3. Myopic choroidal neovascularization

Continuation Criteria

Authorization may be approved for 12 months if:

1. The member is currently receiving therapy with Byooviz.
2. Documentation of positive clinical response is provided, such as improvement or maintenance of best corrected visual acuity (BCVA).

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