Humana: Vabysmo Payer Policy (Beta Access)

TABLE OF CONTENTS

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

This policy outlines the coverage criteria for Vabysmo®, a vascular endothelial growth factor (VEGF) and angiopoietin-2 (Ang-2) inhibitor administered via intravitreal injection. It is indicated for multiple retinal conditions 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, 2023, with a revision date of October 23, 2024, and a review date of October 16, 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).

Diagnoses and Criteria

Neovascular (Wet) Age-Related Exudative 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.

Macular Edema Following Retinal Vein Occlusion (RVO)

• The member is diagnosed with macular edema following retinal vein occlusion.
• 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

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

Dosage and Administration

• Vabysmo is available as:
  • 6 mg solution for intravitreal injection.
• Administration:
  • Dosage and frequency must align with FDA-approved guidelines or clinical standards.

Additional Notes

• Vabysmo inhibits VEGF and Ang-2, reducing vascular permeability and inflammation in the retina.
• It is supported by clinical evidence for treating AMD, DME, and RVO, with demonstrated efficacy in improving visual outcomes and reducing disease progression.

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