CurrentCignaPolicy IP0541

Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Beovu

Defines Cigna medical benefit coverage criteria, dosing, and prior authorization guidance for intravitreal Beovu for ophthalmic neovascular conditions including diabetic macular edema, neovascular AMD, and other neovascular eye diseases; applies to Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyOphthalmology - Vascular Endothelial Growth Factor Inhibitors - Beovu

Policy CodePolicy IP0541

Change TypeTitle revisionadded 'Concomitant Use' exclusion

Effective Date

Next Review Date

Key ActionObtain prior authorization; approval is typically granted for 1 year when criteria and dosing are met.

SourceLink

POLICY UPDATE CHANGES

Policy retitled to 'Ophthalmology - Vascular Endothelial Growth Factor Inhibitors - Beovu' and examples of other neovascular diseases were revised to remove sickle cell neovascularization and choroidal neovascular conditions and to add angioid streaks, iris neovascularization, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy, and presumed ocular histoplasmosis.

Condition 'Concomitant Use with Another Intravitreal Vascular Endothelial Growth Factor Inhibitor' was added to Conditions Not Covered.

3FDA-approved or supported indication groups covered

6 mgapproved per-injection dose

1 yrstandard approval duration

Concomitant VEGFexplicitly listed as not medically necessary

J0179J-code listed for brolucizumab

Coverage Criteria for Beovu (brolucizumab)

Covered Indications and Dosing

Beovu is considered medically necessary when ONE of the following are met (1, 2, or 3):

Indication Group: Any one of the three indication groups (1, 2, or 3) must be met

1. Diabetic Macular Edema: A) Medication is administered by, or under the supervision of an ophthalmologist; AND B) Preferred product criteria is met for the product(s) as listed in the below table(s).

Dosing: 6 mg intravitreal; interval not more frequent than once every 39 days for the first five doses, then not more frequently than every 8 weeks.

2. Neovascular (Wet) Age-Related Macular Degeneration: A) Medication is administered by, or under the supervision of an ophthalmologist; AND B) Preferred product criteria is met for the product(s) as listed in the below table(s).

Dosing: 6 mg intravitreal; interval not more frequent than once every 25 days for the first three doses, then not more frequently than every 8 weeks.

Policy Summary

PayerCigna

PolicyOphthalmology - Vascular Endothelial Growth Factor Inhibitors - Beovu

Policy CodePolicy IP0541

Change TypeTitle revisionadded 'Concomitant Use' exclusion

Effective Date

Next Review Date

Key ActionObtain prior authorization; approval is typically granted for 1 year when criteria and dosing are met.

SourceLink

On This Page

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3. Other Neovascular Diseases of the Eye: A) Medication is administered by, or under the supervision of an ophthalmologist; AND B) Preferred product criteria is met for the product(s) as listed in the below table(s).

Dosing: 6 mg intravitreal; interval not more frequent than once every 25 days for the first three doses, then not more frequently than every 8 weeks. Examples include angioid streaks, iris neovascularization, neovascular glaucoma, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy, and presumed ocular histoplasmosis syndrome.

Beovu used concomitantly with another intravitreal vascular endothelial growth factor (VEGF) inhibitor is considered not medically necessary. There is no evidence to support the concomitant intravitreal use of Beovu with another intravitreal VEGF inhibitor; such requests will be denied as not covered.

Concomitant intravitreal administration of Beovu with any other intravitreal VEGF inhibitor is not covered. Examples of other intravitreal VEGF inhibitors include bevacizumab (repackaged from Avastin® or its biosimilars), aflibercept (Eylea®/biosimilars), ranibizumab (Lucentis®/biosimilars), Susvimo® (ranibizumab via ocular implant), and Vabysmo® (faricimab-svoa). Requests to administer Beovu together with any of these agents will be considered not medically necessary.

Coding and Billing

Considered Medically Necessary when criteria metHCPCSCovered

J0179

Injection, brolucizumab-dbll, 1 mg

Provider Actions, Prior Authorization, and Denial Triggers

Prior Authorization

Prior Authorization Recommended

Prior Authorization is recommended for medical benefit coverage of Beovu. Approval is typically for 1 year when the patient meets the criteria and dosing in the policy. Because of the specialized skills required for evaluation, Beovu must be prescribed by or in consultation with a physician who specializes in the condition being treated (ophthalmologist). Requests for doses outside the established dosing in this policy will be reviewed case-by-case by a clinician.

Approval duration: typically 1 year when criteria and dosing are met
Beovu must be prescribed by, or in consultation with, an ophthalmologist
Requests for off-schedule dosing considered case-by-case by clinician

Step Therapy

Step Therapy — Repackaged Bevacizumab

For Employer and Individual/Family plans, step therapy requires trial of repackaged bevacizumab prior to approval of Beovu unless there is documented inadequate efficacy or intolerance, or the prescriber documents significant safety or supplier concerns with repackaged bevacizumab, or the patient is already receiving Beovu.

Required trial of repackaged bevacizumab unless inadequate efficacy or intolerance demonstrated
Exceptions: prescriber documents safety concerns with repackaged bevacizumab or supplier concerns
Patients currently receiving Beovu are eligible without meeting the repackaged bevacizumab trial requirement

Documentation Required

Required Prescriber & Documentation

The prescriber must document ophthalmologist involvement and provide supporting clinical documentation demonstrating the applicable indication, dosing, prior therapies (if required), and rationale for any exceptions (e.g., safety or supplier concerns with repackaged bevacizumab).

Prescriber requirement: ophthalmologist or consultation with ophthalmologist documented
Include clinical documentation of diagnosis, prior therapy trials, and rationale for exceptions

Denial Risk

Denial Triggers

Requests may be denied if billed without covered diagnosis/procedure codes, if the request is for concomitant intravitreal VEGF inhibitor use, or if required documentation (including prescriber specialty or prior therapy trial documentation) is missing or insufficient.

Denial trigger: Claims billed without covered diagnosis or procedure codes will be denied as not covered
Denial trigger: Requests for concomitant intravitreal VEGF inhibitor use (e.g., bevacizumab [compounded], aflibercept, ranibizumab, Susvimo, Vabysmo) are not medically necessary and will be denied
Denial trigger: Missing documentation of ophthalmologist involvement, prior therapy trials, or rationale for exceptions may result in denial

Background

Vascular endothelial growth factor (VEGF) is a protein that plays a central role in retinal and choroidal physiology and pathology; overexpression of VEGF contributes to neovascularization, increased vascular permeability, macular edema, and vision loss. Intravitreal VEGF inhibitors, including Beovu (brolucizumab), act by inhibiting VEGF-driven neovascularization and reducing vascular leakage and exudation; they are used to treat neovascular age-related macular degeneration, diabetic macular edema, and other neovascular ocular disorders. The policy explicitly excludes concomitant intravitreal use of Beovu with other intravitreal VEGF inhibitors because there is no evidence to support combined intravitreal administration.

Definitions

VEGF — Vascular endothelial growth factor

TermVascular endothelial growth factor (VEGF)

DefinitionA protein that plays a key role in retinal physiology and pathology; overexpression may result in retinal and choroidal neovascularization and vascular leakage.

Clinical relevanceVEGF overexpression contributes to macular edema, neovascularization, and exudation that can lead to vision impairment or loss.

Therapeutic targetIntravitreal VEGF inhibitors (e.g., Beovu) reduce ocular neovascularization, macular edema, and exudation.

Examples of associated conditionsNeovascular (wet) age-related macular degeneration, diabetic macular edema, and other neovascular eye diseases such as angioid streaks, iris neovascularization, neovascular glaucoma, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy, and presumed ocular histoplasmosis syndrome.