Humana: Syfovre Payer Policy (Beta Access)

TABLE OF CONTENTS

• Humana: Syfovre Payer Policy (Testing)
  • Line of Business
  • Precertification/Prior Authorization
  • Diagnoses and Criteria
    • Geographic Atrophy (GA) Secondary to Age-Related Macular Degeneration (AMD)
  • Exclusions
  • Dosage and Administration
  • Additional Notes
  • Sources

This policy outlines the coverage criteria for Syfovre™, a complement inhibitor administered via intravitreal injection. It is indicated for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD) and requires prior authorization for approval.

Line of Business

This policy applies to the following lines of business:

• Medicare
• Commercial

The effective date is May 24, 2023, with a revision date of March 27, 2024, and a review date of March 20, 2024.

Precertification/Prior Authorization

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

Diagnoses and Criteria

Geographic Atrophy (GA) Secondary to Age-Related Macular Degeneration (AMD)

• The member has a diagnosis of geographic atrophy secondary to age-related macular degeneration (AMD).
• Syfovre™ is prescribed by or in consultation with an ophthalmologist or retinal specialist.
• Initial Approval Criteria:
  • Diagnosis of geographic atrophy (GA) secondary to AMD.
  • Prescription by or in consultation with an ophthalmologist or retinal specialist.
  • The member is a candidate for monthly or every-other-month intravitreal injections.
• Approval Duration: Initial approval is for the plan year duration or as determined through clinical review.

Exclusions

• Syfovre™ is contraindicated in:
  • Patients with ocular or periocular infections.
  • Patients with active intraocular inflammation.
• Retinal vasculitis and/or retinal vascular occlusion have been reported, particularly in the presence of intraocular inflammation. These cases may occur with the first dose and can result in severe vision loss. Treatment should be discontinued if such events occur.
• In clinical trials, increased rates of neovascular AMD or choroidal neovascularization were observed (12% with monthly administration, 7% with every-other-month administration, and 3% in the control group by Month 24). Patients should be monitored for signs of neovascular AMD.

Dosage and Administration

• The recommended dose of Syfovre™ is 15 mg (0.1 mL solution) administered by intravitreal injection to each affected eye either monthly or every other month, based on the clinical judgment of the prescribing specialist.

Additional Notes

• Syfovre™ binds to complement protein C3 and its activation fragment C3b, regulating the cleavage of C3 and downstream complement activation.
• Dosage limits beyond 24 months of treatment or for other uses are not specified in this policy.

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