CurrentCignaPolicy IP0541

Brolucizumab (Beovu) intravitreal injection coverage

Defines medical necessity criteria, dosing, continuation, authorization duration, exclusions, and coding for brolucizumab-dbll (Beovu) intravitreal injection for ophthalmic indications (DME, nAMD, and certain other neovascular eye diseases) for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyBrolucizumab (Beovu) intravitreal injection coverage

Policy CodePolicy IP0541

Change TypeAnnual revision — no criteria changes

Effective DateMar 1, 2025

Next Review Date

Key ActionSubmit prior authorization documentation demonstrating indication, ophthalmologist administration/supervision, and either prior bevacizumab failure/contraindication/intolerance or prescriber safety concerns (or current Beovu use) to support coverage.

SourceLink

POLICY UPDATE CHANGES

Annual revision performed with no criteria changes as of 3/1/2025.

6 mgrecommended per-dose strength for each treated eye

up to 12 monthsinitial and reauthorization approval duration

J0179HCPCS code for brolucizumab-dbll, 1 mg

Medical Necessity Criteria for Brolucizumab (Beovu)

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ALL of the following

Treatment indication (ONE required)
- Diabetic macular edema (DME)
- Neovascular (wet) age-related macular degeneration (nAMD)
- Other neovascular diseases of the eye (for example, neovascular glaucoma, retinopathy of prematurity, sickle cell neovascularization, choroidal neovascular conditions)
Medication is administered by, or under the supervision of, an ophthalmologist
Prior therapy / current status (ONE required)
- Currently receiving Beovu
- If not currently receiving Beovu, ONE of the following:
  - Documentation of failure, contraindication, or intolerance to repackaged bevacizumab
  - Prescriber professional opinion that the safety of using the repackaged bevacizumab or the supplier of the repackaged bevacizumab is of significant concern

Dosing & Clinical Thresholds

Dosing interval (DME initial phase)Not more frequent than once every 39 days for five doses (approximately every 39–45 days)

Maintenance interval (DME)Not more frequently than once every 8 weeks (maintenance every 8–12 weeks per prescribing information)

Dosing interval (nAMD initial phase)Not more frequent than once every 25 days for three doses (approximately every 25–31 days)

Maintenance interval (nAMD)Not more frequently than once every 8 weeks (maintenance every 8–12 weeks per prescribing information)

Per-dose strength6 mg administered by intravitreal injection for each eye being treated

What Providers Must Do

Prior Authorization

Medical necessity review / prior authorization

Coverage requires meeting the documented medical necessity criteria: appropriate indication (DME, nAMD, or other neovascular eye disease), administration by or under the supervision of an ophthalmologist, and either current Beovu use or prior bevacizumab failure/contraindication/intolerance or prescriber safety concern.

J0179

Documentation Required

Document prior therapy or safety concerns

If the patient is not currently receiving Beovu, the provider must document either failure, contraindication, or intolerance to repackaged bevacizumab OR the prescriber's professional opinion that the safety of using the repackaged bevacizumab or its supplier is of significant concern.

J0179

Documentation Required

Demonstrate beneficial response for continuation

For reauthorization/continuation of therapy, the provider must document that the initial criteria were met and that a beneficial clinical response to brolucizumab (Beovu) has been demonstrated.

J0179

Clinical and Administrative Background

Beovu (brolucizumab-dbll) is a vascular endothelial growth factor (VEGF) inhibitor indicated for diabetic macular edema (DME) and neovascular (wet) age-related macular degeneration (nAMD). The product is administered by intravitreal injection and is typically provided as a 6 mg dose per treated eye when covered and medically necessary. (See dosing and indications below.)

Recommended dosing differs by indication. For DME, the recommended regimen is 6 mg intravitreal injection every 6 weeks (approximately every 39–45 days) for the first five doses, followed by 6 mg once every 8–12 weeks for maintenance. For nAMD, the recommended regimen is 6 mg intravitreal injection once monthly (approximately every 25–31 days) for the first three doses, followed by 6 mg once every 8–12 weeks for maintenance. These indication‑specific dosing intervals must be followed when coverage is provided.

VEGF inhibitors, including brolucizumab, may also be used off‑label for other neovascular ophthalmic conditions (for example, neovascular glaucoma, retinopathy of prematurity, sickle cell–related neovascularization, and other retinal or choroidal neovascular conditions). Evidence for these additional uses is evolving, and such uses are considered only when supported by clinical rationale and the policy’s medical necessity criteria. Annual policy review was completed with no criteria changes as of 3/1/2025.

Policy Summary

PayerCigna

PolicyBrolucizumab (Beovu) intravitreal injection coverage

Policy CodePolicy IP0541

Change TypeAnnual revision — no criteria changes

Effective DateMar 1, 2025

Next Review Date

SourceLink

On This Page

OpenPayer

Brolucizumab (Beovu) intravitreal injection coverage

Medical Necessity Criteria for Brolucizumab (Beovu)

Billing Codes

What Providers Must Do

Clinical and Administrative Background

Defined Terms

Policy Revision Notes

Brolucizumab (Beovu) intravitreal injection coverage

Medical Necessity Criteria for Brolucizumab (Beovu)

Billing Codes

What Providers Must Do

Clinical and Administrative Background

Defined Terms

Policies to Read With This One

Policy Revision Notes