United Healthcare: Vabysmo Payer Policy

Created by Zoe Stanton, Modified on Mon, 6 Jan at 3:32 PM by C. Denise Burrell

United Healthcare: Vabysmo Payer Policy (Testing)

TABLE OF CONTENTS

United Healthcare: Vabysmo Payer Policy (Testing)
TABLE OF CONTENTS
- MEDICARE PART B

MEDICARE PART B

HCPCS Code(s):	J2777
Precertification Required?	✅ Yes (Click Here for Full Policy)
Step Therapy Required?	✅ Yes (Click Here for Full Policy)
Provider Fax Form:	Vabysmo Fax Form Here (✅ Available in SamaCare)
FDA Approved Indications:	Vabysmo (faricimab-svoa) is proven and medically necessary for the treatment of: Neovascular age-related macular degeneration (nAMD) Diabetic macular edema (DME) Macular edema following retinal vein occlusion (RVO)
Recommended Dosage:

Note:

Initial Approval Criteria

Treatment with Beovu, Byooviz, Cimerli, Eylea HD, Lucentis, Susvimo, or Vabysmo is medically necessary for the treatment of neovascular (wet) age-related macular degeneration (AMD) when one of the following are met: Both of the following: o Trial of at least 3 doses, resulting in minimal clinical response to compounded Avastin (bevacizumab); and o History of use of Eylea, resulting in minimal clinical response to therapy or History of contraindication, intolerance, or adverse event(s) to compounded Avastin (bevacizumab) and Eylea.
History of use of Eylea, resulting in minimal clinical response to therapy; or History of contraindication, intolerance, or adverse event(s) to Eylea; or Both of the following: o History of intolerance, contraindication, or adverse event to Eylea; and o Physician attests that, in their clinical opinion, the same intolerance, contraindication or adverse event would not be expected to occur with Beovu, Byooviz, Cimerli, Eylea HD, Lucentis, Susvimo, or Vabysmo

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

⚠️ 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.

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