Anthem: Vabysmo Payer Policy (Beta Access)

TABLE OF CONTENTS

• TABLE OF CONTENTS
  • Anthem: Vabysmo Payer Policy (Testing)
    • Other Pertinent Information
      • Quantity Limits
      • Exclusion(s)
    • Initial Approval Criteria
    • Continuation Criteria
      • Sources

Note: 
1. Vabysmo may be used after failure or intolerance to a preferred agent.
2. Requests for intravitreal injections of Vabysmo may not be approved when criteria are unmet or for any other indication.

Other Pertinent Information

Vabysmo is a bispecific antibody targeting both VEGF-A and Angiopoietin-2 (Ang-2).

• Quantity Limits:

  • 6 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 granted when the individual has a diagnosis of one of the following:

1. Neovascular (wet) age-related macular degeneration (nAMD).
2. Diabetic macular edema (DME), including with diabetic retinopathy.
3. Macular edema following retinal vein occlusion (RVO).

Continuation Criteria

Authorization for 12 months may be granted if:

1. The individual is currently receiving Vabysmo.
2. Documentation of positive clinical response is provided.

Sources:

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