CurrentCignaPolicy v030126

Beovu (brolucizumab-dbll) prior authorization

This document is a Cigna prior authorization form governing requests for the intravitreal medication Beovu (brolucizumab-dbll) for ocular neovascular conditions; it affects prescribing clinicians, their office staff, and Cigna pharmacy/medical reviewers.

Policy Summary

PayerCigna

PolicyBeovu (brolucizumab-dbll) prior authorization

Policy CodePolicy v030126

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form including required patient and prescriber items, medication name, dose, frequency, duration, ICD-10 diagnosis, and prescriber attestation; fax to (855) 840-1678 or submit via CoverMyMeds/SureScripts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

Beovumedication

brolucizumab-dbllgeneric

Coverage criteria for Beovu (brolucizumab-dbll)

Authorization prerequisites

Coverage considered when ALL of the following form elements are provided and supported:

administrative_and_clinical_information: Completed prior authorization form including required patient and prescriber items; medication name (Beovu), dose, frequency, duration, ICD-10 diagnosis, and prescriber attestation.

Submit via fax to (855) 840-1678 or online at CoverMyMeds/SureScripts per form instructions.

supervision: Indication that the requested medication is administered by or under the supervision of an ophthalmologist (Yes/No).

diagnosis_confirmation: A listed diagnosis related to use is selected (e.g., Diabetic Macular Edema; Neovascular (wet) Age‑Related Macular Degeneration; Other neovascular diseases of the eye).

If 'None of the above' is selected, the form indicates no listed qualifying diagnosis.

Policy Summary

PayerCigna

PolicyBeovu (brolucizumab-dbll) prior authorization

Policy CodePolicy v030126

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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What providers must do to request coverage

Prior Authorization

Prior Authorization Required

Prior authorization required — submit a completed prior authorization form that identifies the medication, dose, frequency, duration of therapy, ICD-10 diagnosis, and the intent of therapy. All asterisked (*) items on the form must be completed; missing required patient or prescriber information may prevent our ability to respond to the request.

Medication requested (identify medication, dose, frequency, duration, ICD-10)
Complete all asterisked (*) items on the prior authorization form
Incomplete patient or prescriber information may prevent review response

Documentation Required

Prior Bevacizumab Use Queried

The prior authorization form asks whether the patient has previously tried repackaged (compounded) bevacizumab and whether the patient demonstrated inadequate efficacy or intolerability to repackaged bevacizumab. The form also requests whether the prescriber has significant safety or supplier concerns about repackaged bevacizumab. Provide responses to these questions to support medical necessity for alternatives.

Has the patient previously tried repackaged bevacizumab? (Yes/No)
Did the patient demonstrate inadequate efficacy or intolerability to repackaged bevacizumab? (Yes/No)
Is safety of repackaged bevacizumab a significant concern to the prescriber? (Yes/No)
Is the supplier of repackaged bevacizumab a significant concern to the prescriber? (Yes/No)

Documentation Required

Required Documentation and Submission

Required documentation and submission — submit the completed prior authorization form including all asterisked items and supporting clinical information. Clinical information should include whether the medication is administered by or under the supervision of an ophthalmologist, whether the requested medication will be used in combination with another intravitreal VEGF inhibitor, current therapy status, prior therapies (including repackaged bevacizumab), and any supporting clinical notes, imaging, or test results that demonstrate inadequate response or intolerance when relevant.

Completed prior authorization form with all asterisked items
Documentation of prescriber specialty and supervision (ophthalmologist)
Statement regarding combination use with other intravitreal VEGF inhibitors
Current therapy status and prior therapies tried
Clinical notes/imaging/labs supporting inadequate efficacy or intolerance to prior therapy

Denial Risk

Incomplete Form Information

Incomplete form information — if required patient or prescriber information is missing or incomplete on the form, we may be unable to process or respond to the prior authorization review. Ensure contact information, Cigna ID, prescriber identifiers (DEA, NPI or TIN), and prescriber signature and date are provided.

Ensure Cigna ID, date of birth, and patient contact information are provided
Provide prescriber DEA, NPI or TIN and specialty
Include prescriber signature and date to attest to the information

Definitions and related therapies

Intravitreal vascular endothelial growth factor inhibitors — examples and form usage

DefinitionIntravitreal vascular endothelial growth factor inhibitors include bevacizumab intravitreal injection (compounded from Avastin or its biosimilars; off-label use), aflibercept intravitreal injection (Eylea and biosimilars, Eylea HD), ranibizumab intravitreal injection (Lucentis and biosimilars), Susvimo (ranibizumab via ocular implant), and Vabysmo (faricimab-svoa).

Examples listed on formBevacizumab (compounded), aflibercept (Eylea/biosimilars), ranibizumab (Lucentis/biosimilars), Susvimo, Vabysmo.

Use contextQuestion on form asks whether Beovu will be used in combination with another intravitreal VEGF inhibitor (Yes/No).

Bevacizumab specificsForm clarifies repackaged bevacizumab is compounded from Avastin (bevacizumab, injection, for intravenous use) or its biosimilars and is considered an off-label intravitreal product.

Purpose of listProvided to identify concurrent intravitreal anti-VEGF agents when assessing Beovu therapy.

OpenPayer

Beovu (brolucizumab-dbll) prior authorization

Coverage criteria for Beovu (brolucizumab-dbll)

Diagnosis and billing codes

What providers must do to request coverage

Background on the medication

Definitions and related therapies