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    v1.0.28
    OpenPayerPolicy UpdatesOphthalmology/OptometryCommunity-Care Beovu Coverage Prior Auth | OpenPay…
    Ask Trek AI about this page
    CurrentCommunity-CarePolicy N/A

    Beovu (brolucizumab) — Medical Benefit Medication Utilization Policy

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    Defines clinical coverage criteria, quantity limits, authorization period, and billing codes for Beovu (brolucizumab) when billed under the medical benefit for neovascular (wet) AMD and diabetic macular edema.

    Policy Summary
    PayerCommunity-Care
    PolicyBeovu (brolucizumab) — Medical Benefit Medication Utilization Policy
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Last ReviewAug 1, 2022
    Next Review DateN/A
    Key ActionObtain prior authorization demonstrating diagnosis and documented trials of bevacizumab and ranibizumab (or documentation they were ineffective, contraindicated, or not tolerated).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Indications covered
    6 mgVial strength
    1 yrAuthorization period

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    J0179
    HCPCS code

    Coverage Criteria

    Initial Therapy — Covered when ALL of the following are met for each indication

    Covered when ALL of the following are met for each indication

    Neovascular (wet) age-related macular degeneration initial criteria: Diagnosis of neovascular (wet) age-related macular degeneration
    Neovascular (wet) age-related macular degeneration initial criteria: Trial of a bevacizumab product was ineffective, contraindicated, or not tolerated
    Neovascular (wet) age-related macular degeneration initial criteria: Trial of a ranibizumab product was ineffective, contraindicated, or not tolerated
    Neovascular (wet) age-related macular degeneration initial criteria: No history of intraocular inflammation or active intraocular inflammation
    Diabetic macular edema initial criteria: Diagnosis of diabetic macular edema
    Diabetic macular edema initial criteria: Trial of a bevacizumab product was ineffective, contraindicated, or not tolerated
    Diabetic macular edema initial criteria: Trial of a ranibizumab product was ineffective, contraindicated, or not tolerated
    Diabetic macular edema initial criteria: No history of intraocular inflammation or active intraocular inflammation

    Quantity Limits / Maintenance Therapy — If approved, dosing limits apply as follows

    If approved, dosing limits apply as follows

    Neovascular (wet) age-related macular degeneration dosing: Loading dose: up to 1 vial (0.05 mL) (6 mg) per eye every 28 days for the first 2 fills; Maintenance dose: 1 vial (0.05 mL) (6 mg) per eye every 56 days (8 weeks).
    Diabetic macular edema dosing: Loading dose: up to 1 vial (0.05 mL) (6 mg) per eye every 42 days (6 weeks) for the first 4 fills; Maintenance dose: 1 vial (0.05 mL) (6 mg) per eye every 56 days (8 weeks).

    Coverage is excluded for members with a history of intraocular inflammation or with active intraocular inflammation. The policy’s initial therapy criteria for both neovascular age‑related macular degeneration and diabetic macular edema require absence of prior or current intraocular inflammation as a condition of coverage.

    Use of brolucizumab without documented prior trials of both a bevacizumab product and a ranibizumab product is not covered unless medical record documentation shows those agents were ineffective, contraindicated, or not tolerated. The policy requires these prior trials (or documentation of why they cannot be used) as part of the coverage determination.

    Coding and Billing

    Applicable HCPCS CodesHCPCS
    J0179Injection, brolucizumab-dbll, 1 mg
    Maintenance dosing interval
    Maintenance dosing interval1 vial (0.05 mL) (6 mg) per eye every 56 days (8 weeks)
    Authorization period if approved1 year
    Vial strength6 mg (0.05 mL)

    Provider Actions and Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required. Requests must document the member’s diagnosis and show prior trials of bevacizumab and ranibizumab (or clear documentation that each was ineffective, contraindicated, or not tolerated) before brolucizumab will be authorized.

    • Applies to all indications covered by this policy (neovascular AMD, diabetic macular edema).
    • Authorization period: up to 1 year if approved.
    Step Therapy

    Step Therapy Requirement

    Step therapy is enforced. A documented prior trial of a bevacizumab product and a ranibizumab product is required unless the provider documents that the agent was ineffective, contraindicated, or not tolerated for this member.

    • Trials must be specific to the current diagnosis (e.g., neovascular AMD or DME).
    • If both prior therapies are not documented as tried and failed/contraindicated/intolerant, the request may be denied.

    Background

    Brolucizumab (Beovu) is an intravitreal anti‑VEGF therapy indicated in this policy for treatment of neovascular (wet) age‑related macular degeneration and diabetic macular edema. The policy defines specific initial‑therapy requirements, loading and maintenance dosing limits, and excludes patients with current or prior intraocular inflammation.

    Dosing Definitions

    Loading dose — neovascular AMD
    Loading dose (neovascular AMD)Up to 1 vial (0.05 mL) (6 mg) per eye every 28 days for the first 2 fills
    Vial strength6 mg (0.05 mL) per vial
    Applies toNeovascular (wet) age-related macular degeneration
    Loading dose — diabetic macular edema
    Loading dose (diabetic macular edema)Up to 1 vial (0.05 mL) (6 mg) per eye every 42 days (6 weeks) for the first 4 fills
    Vial strength6 mg (0.05 mL) per vial
    Applies toDiabetic macular edema
    Policy Summary
    PayerCommunity-Care
    PolicyBeovu (brolucizumab) — Medical Benefit Medication Utilization Policy
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Last ReviewAug 1, 2022
    Next Review DateN/A
    Key ActionObtain prior authorization demonstrating diagnosis and documented trials of bevacizumab and ranibizumab (or documentation they were ineffective, contraindicated, or not tolerated).
    SourceLink
    On This Page
    Coverage CriteriaCoding and BillingProvider Actions and RequirementsBackgroundDosing Definitions
    Documentation Required

    Required Clinical Documentation

    Provide clinical documentation that supports the diagnosis and prior therapy outcomes. Documentation should include relevant clinical findings, dates and duration of prior anti-VEGF treatments, reason for discontinuation or failure (ineffective, adverse event, contraindication, or intolerance), and any imaging or examiner notes supporting the need for brolucizumab.

    • Diagnosis documentation (e.g., neovascular AMD or diabetic macular edema).
    • Records of bevacizumab and ranibizumab trials with dates, doses, response, and reason for change.
    • Ocular exam findings and imaging (OCT, fluorescein angiography) as available.
    Denial Risk

    Denial Risk — Missing Prior Therapy or Intraocular Inflammation

    Requests lacking documented prior trials of bevacizumab and/or ranibizumab, or lacking documentation that those agents were ineffective, contraindicated, or not tolerated, are at high risk for denial. Requests will also be denied if there is a history of intraocular inflammation or active intraocular inflammation without adequate risk justification.

    • Missing prior anti-VEGF therapy records = likely denial.
    • Documented history of intraocular inflammation or active inflammation = contraindication to brolucizumab and may result in denial.
    Maintenance dose
    Maintenance dose1 vial (0.05 mL) (6 mg) per eye every 56 days (8 weeks)
    Vial strength6 mg (0.05 mL) per vial
    IndicationsApplies after loading for neovascular AMD and diabetic macular edema