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)
  • Continuation Criteria
  • 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 lines of business:

• Medicare
• Medicaid – Florida
  • Step therapy requirements do not apply.
• 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.

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] or visual field, or a reduction in the rate of vision decline or risk of more severe vision loss).
• Medicare Requests:
  • 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.
  • Previous treatment, intolerance, or contraindication to at least one of the following: Byooviz, Cimerli, Eylea, Eylea HD, Vabysmo.
• Florida Medicaid Requests:
  • Step therapy requirements do not apply.

Diagnoses and Criteria

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

• The member has a diagnosis of neovascular (wet) age-related macular degeneration.
• Beovu® must be prescribed by or in consultation with an ophthalmologist or retinal specialist.
• 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 has a diagnosis of diabetic macular edema.
• Beovu® must be prescribed by or in consultation with an ophthalmologist or retinal specialist.
• 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.

Continuation Criteria

• Documentation must demonstrate that the member has achieved or maintained a positive clinical response, such as:
  • Stabilization or improvement in BCVA.
  • Reduced rate of disease progression (e.g., vision decline or new lesions).
• Requests for continued treatment beyond initial approval require 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.
• Recommended administration:
  • Initial doses: Monthly injections for the first three doses.
  • Maintenance: One injection every 8 to 12 weeks thereafter.

Additional Notes

• Beovu binds to and inhibits VEGF-A, reducing abnormal blood vessel growth and leakage in the retina.
• 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