Humana: Susvimo Payer Policy (Beta Access)

TABLE OF CONTENTS

• Humana: Susvimo Payer Policy (Testing)
  • Line of Business
  • Precertification/Prior Authorization
  • Step Therapy
  • 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 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 line of business:

• Medicaid – Louisiana

The effective date is January 1, 2024, with a revision date of June 26, 2024, and a review date of June 19, 2024.

Precertification/Prior Authorization

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

Step Therapy

• The member must have:
  • A contraindication, intolerance, or inadequate response to bevacizumab; OR
  • Prior therapy with at least 2 intravitreal injections of a VEGF inhibitor (e.g., bevacizumab, Eylea, Lucentis).
• Exceptions:
  • Step therapy requirements do not apply for continuation of therapy where Susvimo™ was initiated previously and successfully in the affected eye(s).

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.
• Step therapy requirements as outlined above must be met.
• The provider must attest that the member has not demonstrated a positive clinical response to previous treatments (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).
• 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.
• Concurrent use of Susvimo™ with other VEGF inhibitors is not recommended unless documentation specifies that the products are being 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.
• It is specifically indicated for patients who have previously responded to at least two intravitreal injections of a VEGF inhibitor.

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