Humana: Susvimo Payer Policy (Beta Access)

TABLE OF CONTENTS

• Humana: Susvimo Payer Policy (Testing)
  • Line of Business
  • Precertification/Prior Authorization
  • Diagnoses and Criteria
    • Neovascular (Wet) Age-Related Exudative Macular Degeneration (AMD)
  • Exclusions
  • Dosage and Administration
  • Additional Notes
  • Sources

This policy outlines the coverage criteria for Susvimo™, a recombinant monoclonal antibody and vascular endothelial growth factor (VEGF) inhibitor administered via intravitreal injection through an ocular implant. It is indicated for the treatment of neovascular (wet) age-related macular degeneration (AMD) and requires prior authorization for approval.

Line of Business

This policy applies to the following lines of business:

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

The effective date is January 1, 2025, with a revision date of January 1, 2025, and a review date of May 15, 2024.

Precertification/Prior Authorization

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

Diagnoses and Criteria

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

• The member has a diagnosis of neovascular (wet) age-related macular degeneration.
• Susvimo™ must be used in conjunction with the Susvimo ocular implant.
• The member has a contraindication or intolerance to bevacizumab, OR has had prior therapy with bevacizumab and has not demonstrated a positive clinical response (e.g., improvement or maintenance in best corrected visual acuity (BCVA) or visual field, or a reduction in the rate of vision decline or the risk of severe vision loss).
• Medicare Part B Requests:
  • Step therapy does not apply if the request is a continuation of prior therapy within the past 365 days.
• Florida Medicaid Requests:
  • Step therapy requirements do not apply.
• Commercial and Medicaid Requests:
  • The member must have had prior therapy with at least 2 intravitreal injections of a VEGF inhibitor (e.g., bevacizumab, Eylea, Lucentis).
• Medicare Requests:
  • The member must have had previous treatment, intolerance, or contraindication to at least one VEGF inhibitor (e.g., Byooviz, Cimerli, Eylea, Eylea HD, Vabysmo).
• Approval Duration: Initial approval is for the plan year duration or as determined through clinical review.

Exclusions

• Susvimo™ is contraindicated in:
  • Patients with active intraocular inflammation.
  • Patients with ocular or periocular infections.
• Susvimo™ should not be used concurrently with other VEGF inhibitors for intraocular use unless documentation indicates that individual products are to be used in different eyes.

Dosage and Administration

• Susvimo™ is available as a 100 mg/mL solution for intravitreal injection via an ocular implant.

Additional Notes

• Susvimo™ binds to and inhibits VEGF-A, reducing the growth of abnormal blood vessels beneath the retina.
• Susvimo™ is indicated for patients who have previously responded to at least two intravitreal injections of a VEGF inhibitor.
• Dosage limits and long-term use beyond FDA-approved guidelines are not detailed in this policy.

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