CurrentCareSourcePolicy N/A

Ophthalmology Vascular Endothelial Growth Factor Inhibitors Beovu Utilization Management Medical Policy

Defines prior authorization criteria, dosing requirements, approved indications (FDA-approved: diabetic macular edema and neovascular age-related macular degeneration) and other supported neovascular eye diseases for medical-benefit coverage of Beovu, and states non-coverage for indications not listed.

Policy Summary

PayerCareSource

PolicyOphthalmology Vascular Endothelial Growth Factor Inhibitors Beovu Utilization Management Medical Policy

Policy CodePolicy N/A

Change TypeClarified (annual revisionno criteria changes)

Effective Date

Next Review Date

Key ActionPrior Authorization is recommended for Beovu; approve for patients who meet the stated criteria and dosing, with approvals provided for 1 year.

SourceLink

POLICY UPDATE CHANGES

Annual Revision noted with 'No criteria changes' and Review Date 11/15/2023; latest review date listed as 11/20/2024.

2FDA-Approved Indications Listed

1Approval Duration (years)

1Specialist Prescriber Required

Coverage Summary

This policy defines prior authorization criteria for medical-benefit coverage of Beovu including dosing requirements and approved indications. Coverage is recommended for the FDA-approved indications: diabetic macular edema (DME) and neovascular (wet) age-related macular degeneration (nAMD) when administered by or under the supervision of an ophthalmologist and when dosing meets the specified dose and interval requirements. The policy also supports use for other neovascular eye diseases with supportive evidence. Coverage is not recommended for indications or circumstances not listed in the Recommended Authorization Criteria.

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Initial Therapy Criteria

FDA-Approved Indications - Diabetic Macular Edema (DME)

Approve for 1 year if administered by or under the supervision of an ophthalmologist. Dosing: Approve if the requested dosing meets BOTH of the following (A and B):

ALL of the following

Dose is 6 mg administered by intravitreal injection for each eye treated6 mg
Dosing interval is not more frequent than once every 39 days for five doses, followed by not more frequently than once every 8 weeks for each eye being treatedNot more frequent than once every 39 days for five doses, then every 8 weeks
Prescriber: Administered by or under the supervision of an ophthalmologist

FDA-Approved Indications - Neovascular (Wet) Age-Related Macular Degeneration (nAMD)

Approve for 1 year if administered by or under the supervision of an ophthalmologist. Dosing: Approve if the requested dosing meets BOTH of the following (A and B):

ALL of the following

Dose is 6 mg administered by intravitreal injection for each eye being treated6 mg
Dosing interval is not more frequent than once every 25 days for three doses, followed by not more frequently than once every 8 weeks for each eye being treatedNot more frequent than once every 25 days for three doses, then every 8 weeks
Prescriber: Administered by or under the supervision of an ophthalmologist

Other Uses with Supportive Evidence - Other Neovascular Diseases of the Eye

Approve for 1 year if administered by or under the supervision of an ophthalmologist. Examples include neovascular glaucoma, retinopathy of prematurity, sickle cell neovascularization, choroidal neovascular conditions. Dosing: Approve if BOTH A and B are met:

ALL of the following

Dose is 6 mg administered by intravitreal injection for each eye treated6 mg
Dosing interval is not more frequent than once every 25 days for three doses, followed by not more frequently than once every 8 weeks for each eye being treatedNot more frequent than once every 25 days for three doses, then every 8 weeks
Prescriber: Administered by or under the supervision of an ophthalmologist

Unproven / Not Recommended

Conditions Not Recommended for Approval

Coverage is not recommended when criteria are not met or for circumstances not listed in the Recommended Authorization Criteria.

ANY of the following

Not recommended indication: Requests for indications not listed in the Recommended Authorization Criteria
Coverage not recommended when criteria are not met or indication not listed

Provider Actions & Authorization Requirements

Prior Authorization

Prior authorization required

Prior Authorization is recommended for medical benefit coverage of Beovu. Approval is recommended for patients who meet the stated criteria and dosing. All approvals are provided for the duration noted (1 year for listed indications).

Documentation Required

Specialist prescribing requirement

Beovu must be prescribed by or in consultation with a physician who specializes in the condition being treated (ophthalmologist).

Billing Rule

Requests outside established dosing

Requests for doses outside of the established dosing documented in this policy will be considered on a case-by-case basis by a clinician (Medical Director or Pharmacist).

Clinical Evidence

Beovu (brolucizumab) is a vascular endothelial growth factor (VEGF) inhibitor indicated for neovascular (wet) age-related macular degeneration (nAMD) and diabetic macular edema (DME). VEGF inhibitors may also be used off-label for other neovascular ophthalmic conditions (for example, neovascular glaucoma, retinopathy of prematurity, and choroidal neovascular conditions); evidence for these uses is evolving. Primary prescribing information: Beovu intravitreal injection prescribing information, Novartis; July 2024.

Policy Summary

PayerCareSource

PolicyOphthalmology Vascular Endothelial Growth Factor Inhibitors Beovu Utilization Management Medical Policy

Policy CodePolicy N/A

Change TypeClarified (annual revisionno criteria changes)

Effective Date

Next Review Date

Key ActionPrior Authorization is recommended for Beovu; approve for patients who meet the stated criteria and dosing, with approvals provided for 1 year.

SourceLink

On This Page

OpenPayer

Ophthalmology Vascular Endothelial Growth Factor Inhibitors Beovu Utilization Management Medical Policy

Coverage Summary

Initial Therapy Criteria

Continuation Therapy Criteria

Unproven / Not Recommended

Applicable Codes

Provider Actions & Authorization Requirements

Clinical Evidence

Background & Definitions

Revision History