CurrentCareSourcePolicy N/A

Vabysmo (faricimab-svoa) coverage for retinal diseases

Defines prior authorization requirements, coverage criteria, dosing guidance, and authorization durations for Vabysmo when used to treat neovascular (wet) AMD, diabetic macular edema (DME), and macular edema following retinal vein occlusion (RVO) for CareSource members in Arkansas PASSE.

Policy Summary

PayerCareSource

PolicyVabysmo (faricimab-svoa) coverage for retinal diseases

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document baseline BCVA and prior bevacizumab failure.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3indications listed (nAMD, DME, RVO)

6 moinitial approval duration

12 moreauthorization duration

≥18minimum member age (yrs)

PA Requiredbenefit status

Coverage Criteria for Vabysmo (faricimab‑svoa)

Initial Therapy

Covered when ALL of the following are met for initial authorization:

Initial Authorization: Member is at least 18 years of age; medication prescribed by or in consultation with an ophthalmologist; diagnosis of neovascular (wet) AMD OR diabetic macular edema (DME) OR macular edema following retinal vein occlusion (RVO); documentation of best-corrected visual acuity (BCVA); member does NOT have active infection or inflammation in or around the eye(s) to be treated; member has tried and failed bevacizumab intravitreal injection; dosage/quantity limits per package insert (AMD: 6 mg every 4 weeks x4 doses then adjust to every 4–16 weeks; DME: 6 mg every 4 weeks x4–6 doses then adjust to every 4–8 weeks; RVO: 6 mg every 4 weeks for 6 months; quantity limit 1 vial or prefilled syringe per eye per 28 days); approval duration 6 months.

Dosage specifics per package insert: see text.

Continuation Therapy / Reauthorization

Covered when ALL of the following are met for reauthorization:

Reauthorization: Chart notes document improved or stabilized visual acuity compared to baseline; other ongoing clinical assessment per prescriber; approval duration 12 months when met.

Policy Summary

PayerCareSource

PolicyVabysmo (faricimab-svoa) coverage for retinal diseases

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document baseline BCVA and prior bevacizumab failure.

SourceLink

On This Page

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CareSource considers Vabysmo (faricimab‑svoa) medically necessary only when used for the specific retinal indications listed in this policy (neovascular [wet] age‑related macular degeneration, diabetic macular edema, and macular edema following retinal vein occlusion) and only when the coverage criteria in this document are met. Use of Vabysmo for conditions not specified in this policy is not covered under this document; requests for off‑label indications must be supported by appropriate literature or clinical justification in accordance with the plan’s Off‑Label use requirements.

Treatment with Vabysmo for diagnoses other than neovascular (wet) AMD, diabetic macular edema (DME), or macular edema following retinal vein occlusion (RVO) is considered not medically necessary.

Coding, Age, and Related Identifiers

Neutral / Codes not listedmixed

NDC/CPT/HCPCS not specified

No specific billing codes listed in document; policy designates Vabysmo as Medical benefit.

Age

Minimum member age>= 18 years

Policy effective date (reference)Document effective/use: Vabysmo coverage criteria (FDA approval 2022) per Arkansas PASSE policy

Approval duration at initial authorization6 months when initial criteria met

Provider Requirements and Prior Authorization Actions

Prior Authorization

Prior Authorization Required

Vabysmo (faricimab-svoa) is covered as a medical benefit and requires prior authorization for the listed retinal indications. Requests should be submitted before administration and must include clinical documentation supporting the diagnosis and treatment plan.

Benefit type: Medical
Prior authorization required for nAMD, DME, and macular edema following RVO
Physician-prescribed or in consultation with an ophthalmologist

Step Therapy

Prior Anti-VEGF Trial Requirement

A step-therapy requirement applies: the member must have tried and failed intravitreal bevacizumab prior to consideration of Vabysmo. Documentation should indicate prior bevacizumab administration and reason for failure (lack of efficacy or intolerance).

Prior anti-VEGF trial required: intravitreal bevacizumab
Document number of injections, dates, and clinical response or adverse effects

Documentation Required

Required Clinical Documentation

Include required clinical documentation with the prior authorization: baseline best-corrected visual acuity (BCVA) for initial authorization and chart notes showing improved or stabilized visual acuity for reauthorization. Also confirm age (≥18) and absence of active ocular infection or inflammation.

Initial authorization: BCVA at baseline, diagnosis, prescriber specialty
Reauthorization: chart notes documenting improved or stabilized visual acuity
Clinical contraindications: absence of active infection or inflammation in/around treated eye(s)

Denial Risk

Requests may be denied if submitted documentation does not demonstrate that the member meets all policy criteria (e.g., age ≥18, correct diagnosis, prior bevacizumab trial, required clinical measurements). Ensure complete records are provided to avoid denial.

Denial risk if missing proof of prior bevacizumab trial or inadequate clinical notes
Denial risk if member is under 18 or has active ocular infection/inflammation
Denial risk if diagnosis is not one of the listed indications

Definitions

BCVA (Best-corrected visual acuity)

DefinitionBest-corrected visual acuity (BCVA): documentation of visual acuity used as a baseline and to demonstrate stabilization or improvement for reauthorization.

Role at initial authorizationBCVA must be documented in chart notes as part of initial authorization requirements.

Role for reauthorizationChart notes must document improved or stabilized visual acuity compared to baseline for reauthorization.

Background

Vabysmo (faricimab‑svoa) is a bispecific monoclonal antibody that inhibits both vascular endothelial growth factor A (VEGF‑A) and angiopoietin‑2 (Ang‑2). This dual inhibition targets neovascularization and vascular permeability while Ang‑2 blockade is thought to stabilize the retinal vasculature and reduce susceptibility to VEGF‑driven leakage. Vabysmo is approved for the treatment of specified retinal diseases and is authorized under this policy only for the indications listed and when the applicable coverage criteria are satisfied.