United Healthcare: Beovu Payer Policy

Created by Zoe Stanton, Modified on Thu, 16 Jan at 5:22 PM by C. Denise Burrell

United Healthcare: Beovu Payer Policy (Testing)

TABLE OF CONTENTS

United Healthcare: Beovu Payer Policy (Testing)

MEDICARE PART B

HCPCS Code(s):	J0179
Precertification Required?	Yes (Click Here For Full Policy)
Step Therapy Required?	Yes (Click Here For Full Policy)
Provider Fax Form:	Yes (✅ Available in SamaCare) Though this form is available in SamaCare, UHC may not accept faxed submissions. Instead, practices are encouraged to use the payer portal, which can be accessed directly through SamaCare!
FDA Approved Indications:	Neovascular (Wet) Age-Related Macular Degeneration (nAMD). Diabetic Macular Edema (DME).
Recommended Dosage:	Not Specified - Maximum Dosage & Frequency

Note: Coverage applies to UnitedHealthcare Medicare Advantage plans under the Medicare Part B Step Therapy Programs.

Non-Employer Group Medicare Advantage

Erickson Advantage® plans: H5652-001 through H5652-008
UnitedHealthcare Medicare Direct (Private Fee-For-Service, PFFS): H5435-001, H5435- 024
Certain UnitedHealthcare Dual Complete and Dual Choice plans:
- Arizona: H0321-004
- District of Columbia: H2228-045, H2406-053, H2406-099, H7464-010
- Florida: H2509-001
- Minnesota: H0845-001, H7778-001, H7778-002
- New Jersey: H3113-005
- New York: H3387-013
- Tennessee: H0251-004
- Virginia: H7464-005, H7464-007
UnitedHealthcare Connected plans(Medicare-Medicaid)
- Massachusetts: H9239-001
- Ohio: H2531-001
- Texas: H7833-001
UnitedHealthcare Senior Care Options in Massachusetts: H2226-001, H2226-003

Employer Group Medicare Advantage

All Group HMO plans
Select Group PPO plans:
- Bristol-Myers Squibb: H2001-869
- Johnson & Johnson: H2001-869
- United Auto Workers (UAW) Trust: H2001-870
- U.S. Government of the Virgin Islands (USGVI): H2001-859, H2001-868
- Verizon: H2001-869

Beovu is considered a non-preferred product.

Step therapy criteria require:
- Trial of compounded Avastin with minimal clinical response, followed by
- Trial of Eylea with minimal clinical response, or
- Documentation of intolerance, contraindications, or adverse events with both compounded Avastin and Eylea.

Other Pertinent Information:

Avastin is recognized as the cost-effective first-line therapy within its class.
Licensed compounding pharmacies must follow strict guidelines for sterile preparation and storage.

Quantity Limits:

Limited to 12 injections per year per eye.

Initial Approval Criteria

A documented diagnosis of nAMD or DME.
Fulfillment of step therapy requirements, including trials of Avastin and Eylea or documented contraindications/intolerances.

Continuation Criteria

Documentation of a positive clinical response, such as stabilization or improvement in disease symptoms, is required for continued therapy.

Medicare Part B Sources:

Additional Resources

https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/125387lbl.pdf

MEDICAID

HCPCS Code(s):	J0179
Precertification Required?	Yes (Click Here for Full Policy)
Step Therapy Required?	Yes (Click Here for Full Policy)
Provider Fax Form:	Generic Form (✅ Available in SamaCare) Though this form is available in SamaCare, UHC may not accept faxed submissions. Instead, practices are encouraged to use the payer portal, which can be accessed directly through SamaCare!
FDA Approved Indications:	Neovascular (Wet) Age-Related Macular Degeneration (nAMD). Diabetic Macular Edema (DME).
Recommended Dosage:	Not Specified - Maximum Dosage & Frequency

Note: This Medical Benefit Drug Policy does not apply to the states listed below; refer to the state-specific policy/guideline, if noted:

State	Policy/Guide Line
Indiana	Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Indiana Only)
Kansas	Refer to the state’s Medicaid clinical policy
Louisiana	Not Specified
North Carolina	Not Specified
Ohio	Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors (for Ohio Only)
Pennsylvania	Refer to the state’s Medicaid clinical policy

Treatment with Beovu is considered medically necessary after:

A documented trial of compounded Avastin (bevacizumab) with minimal clinical response; and
A documented trial of Eylea (aflibercept) with minimal clinical response, or
Documentation of intolerance, contraindication, or adverse events with both Avastin and Eylea.

Other Pertinent Information

Licensed compounding pharmacies must ensure adherence to strict guidelines for the preparation, transportation, and storage of sterile products.

Dosages and Administration:

Beovu is administered via intravitreal injection as directed by clinical guidelines.
Dosage specifics are not detailed in this document.

Quantity Limits:
Limited to 12 doses per year per eye, regardless of the diagnosis.

Initial Approval Criteria

A confirmed diagnosis of nAMD or DME.
Documentation of prior trials and failures or contraindications to Avastin and Eylea.

Continuation Criteria

Documentation of positive clinical response, such as stabilization or improvement in disease symptoms.
Adherence to quantity limits of 12 doses per year per eye.

Medicaid Sources:

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/ophthalmologic-vascular-endothelial-growth-factor-inhibitors-cs.pdf

Additional Resources

Maximum Dosage and Frequency https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/maximum-dosage-policy-cs.pdf

Macular Degeneration Treatment Procedures https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/macular-degeneration-treatment-procedures-cs.pdf

COMMERCIAL

HCPCS Code(s):	J0179
Precertification Required?	Yes (Click Here For Full Policy)
Step Therapy Required?	Yes (Click Here For Full Policy)
Provider Fax Form:	Generic Form (✅ Available in SamaCare) Though this form is available in SamaCare, UHC may not accept faxed submissions. Instead, practices are encouraged to use the payer portal, which can be accessed directly through SamaCare!
FDA Approved Indications:	Neovascular (Wet) Age-Related Macular Degeneration (nAMD) Diabetic Macular Edema (DME)
Recommended Dosage:	Not Specified - Maximum Dosage & Frequency

Note: Coverage is provided under UnitedHealthcare Commercial plans, contingent upon the criteria outlined in the General Requirements and Diagnosis-Specific Requirements sections.

Other Pertinent Information

Adherence to the United States Pharmacopeia (USP) Chapter 797 standards for compounding, transportation, and storage of sterile products is mandatory.

Quantity Limits:

Beovu administration is limited to no more than 12 doses per year per eye, regardless of diagnosis.

Dosages and Administration:

Intravitreal administration as directed in clinical guidelines.

Initial Approval Criteria

Approval for Beovu requires:
- A documented diagnosis of one of the FDA-approved indications.
- Compliance with the policy’s step therapy requirements.

Continuation Criteria

Documentation of positive clinical response to Beovu, such as stabilization or improvement in disease progression.
Adherence to the quantity limits specified.

Commercial Sources:

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/ophthalmologic-vegf-inhibitors.pdf?

Additional Resources:

⚠️ Disclaimer: This article is a policy summary and does not guarantee coverage or approval. Policies may vary based on plan, payer-specific rules, state or regional requirements, benefit structure, formulary placement, and patient-specific considerations like diagnosis or clinical history. Always review the full policy and confirm details directly with the payer to ensure compliance.

We're here to guide you through your prior authorization quest!

United Healthcare: Beovu Payer Policy

United Healthcare: Beovu Payer Policy (Testing)

MEDICARE PART B

Other Pertinent Information:

Quantity Limits:

Initial Approval Criteria

Continuation Criteria

Medicare Part B Sources:

MEDICAID

Other Pertinent Information

Dosages and Administration:

Beovu is administered via intravitreal injection as directed by clinical guidelines.Dosage specifics are not detailed in this document.

Quantity Limits:Limited to 12 doses per year per eye, regardless of the diagnosis.

Initial Approval Criteria

Medicaid Sources:

COMMERCIAL

Other Pertinent Information

Dosages and Administration:

Initial Approval Criteria

Commercial Sources:

Beovu is administered via intravitreal injection as directed by clinical guidelines.
Dosage specifics are not detailed in this document.

Quantity Limits:
Limited to 12 doses per year per eye, regardless of the diagnosis.