Humana: Byooviz Payer Policy (Beta Access)

TABLE OF CONTENTS

• Line of Business
• Precertification/Prior Authorization
• Step Therapy
• Diagnoses and Criteria
  • Neovascular (Wet) Age-Related Exudative Macular Degeneration (AMD)
  • Macular Edema Following Retinal Vein Occlusion (RVO)
  • Myopic Choroidal Neovascularization (mCNV)
• Exclusions
• Additional Notes
• Sources

This policy outlines the coverage criteria for Byooviz™, a recombinant monoclonal antibody and vascular endothelial growth factor (VEGF) inhibitor administered via intravitreal injection. It is indicated for multiple ophthalmological conditions and requires prior authorization for approval.

Line of Business

This policy applies to the following lines of business:

• Medicare
• Commercial
• Medicaid – Florida
• Medicaid – Kentucky
• Medicaid – South Carolina
• Medicaid – Ohio

The effective date is June 22, 2022, with a revision date of July 1, 2024, and a review date of May 15, 2024.

Precertification/Prior Authorization

• Required: Yes, prior authorization is required for all covered indications.

Step Therapy

• Members must have a contraindication or intolerance to bevacizumab OR must have had prior therapy with bevacizumab, and the provider must attest that the member has not demonstrated a positive clinical response (e.g., improvement or maintenance in best-corrected visual acuity, visual field, or a reduction in the rate of vision decline).
• Exceptions:
  • For Medicare Part B requests, the step therapy requirement does not apply if the request is a continuation of prior therapy within the past 365 days.
  • Step therapy does not apply to Florida Medicaid requests.

Diagnoses and Criteria

Neovascular (Wet) Age-Related Exudative Macular Degeneration (AMD)

• The member has a diagnosis of neovascular (wet) age-related macular degeneration.
• Step therapy requirements apply as outlined above.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Macular Edema Following Retinal Vein Occlusion (RVO)

• The member has a diagnosis of macular edema following retinal vein occlusion.
• Step therapy requirements apply as outlined above.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Myopic Choroidal Neovascularization (mCNV)

• The member has a diagnosis of myopic choroidal neovascularization.
• Step therapy requirements apply as outlined above.
• Approval Duration: Approval is for the plan year duration or as determined through clinical review.

Exclusions

• Byooviz is contraindicated in:
  • Patients with ocular or periocular infections.
• Concurrent use of Byooviz with other VEGF inhibitors is not recommended unless documentation specifies that the products are being used in different eyes.

Additional Notes

• Dosage, quantity limits, and continuation criteria are not specified in the policy.

Sources: https://mcp.humana.com/tad/tad_new/home.aspx?type=provider