Humana: Beovu Payer Policy (Beta Access)

TABLE OF CONTENTS

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

This policy outlines the coverage criteria for Beovu®, a vascular endothelial growth factor (VEGF) inhibitor administered via intravitreal injection. It is indicated for the treatment of neovascular (wet) age-related macular degeneration (AMD) and diabetic macular edema (DME). Prior authorization is required for approval.

Line of Business

This policy applies to the following line of business:

• Medicaid – Indiana

The effective date is July 1, 2024, with a revision date of July 1, 2024, and a review date of February 21, 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 bevacizumab, and the provider attests that the member has not demonstrated a positive clinical response (e.g., improvement or maintenance in best corrected visual acuity [BCVA], visual field, or a reduction in the rate of vision decline or the risk of severe vision loss).

Diagnoses and Criteria

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

• The member is diagnosed with neovascular (wet) age-related macular degeneration.
• Step therapy requirements as outlined above must be met.
• Approval Duration: Initial approval is for the plan year duration or as determined through clinical review.

Diabetic Macular Edema (DME)

• The member is diagnosed with diabetic macular edema.
• Step therapy requirements as outlined above must be met.
• Approval Duration: Initial approval is for the plan year duration or as determined through clinical review.

Exclusions

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

Dosage and Administration

• Beovu is available as:
  • 6 mg/0.05 mL solution for intravitreal injection.

Additional Notes

• Beovu binds to and inhibits VEGF-A, reducing abnormal blood vessel growth and leakage in the retina.
• Age-related macular degeneration (AMD) is a leading cause of vision loss in individuals over 60.
• Diabetic macular edema (DME) results from poorly controlled diabetes, leading to retinal edema and hypoxia, which stimulates VEGF production.

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