Currentculinary health fundPolicy N/A

Beovu (brolucizumab) intravitreal injection coverage

This policy governs prior authorization and medical benefit coverage criteria for Beovu (brolucizumab intravitreal injection) for ophthalmic indications, affecting prescribers and prior authorization reviewers within Culinary Health Fund's jurisdiction.

Policy Summary

Payerculinary health fund

PolicyBeovu (brolucizumab) intravitreal injection coverage

Policy CodePolicy N/A

Change TypeMaterial additions and revisions

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and ensure Beovu is prescribed by or in consultation with an ophthalmologist and that dosing meets the policy-specified criteria.

SourceLink

POLICY UPDATE CHANGES

Other Neovascular Diseases of the Eye was added as an approval category with examples.

A policy exclusion was added disallowing concomitant use of Beovu with another intravitreal VEGF inhibitor.

The examples in the note regarding other neovascular diseases were revised to remove sickle cell neovascularization and choroidal neovascular conditions.

2FDA-approved indications listed

6 mgApproved dose per injection

1 yrTypical approval duration

Concomitant use

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Coverage and Authorization Criteria

FDA-Approved Indications

Covered for FDA-approved indications when ALL of the following are met

Diabetic Macular Edema (DME): Approve for 1 year if administered by or under the supervision of an ophthalmologist.Dose = 6 mg administered by intravitreal injection per eye; Interval = not more frequent than once every 39 days for the first five doses, then not more frequently than once every 8 weeks per eye.

Both dose and interval conditions A and B must be met.

Neovascular (Wet) Age-Related Macular Degeneration (AMD): Approve for 1 year if administered by or under the supervision of an ophthalmologist.Dose = 6 mg administered by intravitreal injection per eye; Interval = not more frequent than once every 25 days for the first three doses, then not more frequently than once every 8 weeks per eye.

Both dose and interval conditions A and B must be met.

Other Uses with Supportive Evidence

Covered for other neovascular eye diseases when ALL of the following are met

Other Neovascular Diseases of the Eye: Approve for 1 year if administered by or under the supervision of an ophthalmologist.Dose = 6 mg administered by intravitreal injection per eye; Interval = not more frequent than once every 25 days for the first three doses, then not more frequently than once every 8 weeks per eye.

Examples include angioid streaks, iris neovascularization, neovascular glaucoma, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy, and presumed ocular histoplasmosis syndrome.

Concomitant use of Beovu with another intravitreal vascular endothelial growth factor (VEGF) inhibitor is not recommended and will not be approved.

Coverage of Beovu is not recommended for circumstances that are not explicitly listed in the Recommended Authorization Criteria; the criteria will be updated as new published data become available.

Requests for concomitant intravitreal VEGF inhibitor use are not supported by the evidence and therefore will be denied. The policy notes there is no evidence to support administering Beovu together with another intravitreal VEGF inhibitor and considers such combined use not medically supported for approval.

Actions Required by Prescribers and Reviewers

Prior Authorization

Prior Authorization Required

Prior authorization is required for medical benefit coverage of Beovu. Approvals are recommended for members who meet the policy's indication and dosing criteria. Approvals are issued for the duration specified in the policy (typically 1 year for approved indications). Automation: None.

Prior authorization required for Beovu for medical benefit coverage
Approvals issued for duration noted in policy (typical: 1 year)
Beovu must be prescribed by or in consultation with a physician who specializes in the condition being treated (eg, ophthalmologist)

Prior Authorization

Non‑standard Dosing Reviewed Case‑by‑Case

Requests for dosing outside the established dosing and interval parameters described in the policy will be reviewed on a case‑by‑case basis by a clinician (e.g., Medical Director or Pharmacist). Such non‑standard dosing requests require supporting justification and relevant clinical documentation demonstrating why the standard dosing cannot be followed.

Background and Drug Information

Beovu (brolucizumab) is a vascular endothelial growth factor (VEGF) inhibitor administered by intravitreal injection to reduce ocular neovascularization, macular edema, and retinal exudation. It is used to treat FDA‑approved indications such as diabetic macular edema and neovascular (wet) age‑related macular degeneration, and intravitreal VEGF inhibitors may also be used for other neovascular eye diseases.

Key Definitions

VEGF — vascular endothelial growth factor and role

DefinitionVascular endothelial growth factor (VEGF) is a protein that plays a key role in retinal physiology and pathology; overexpression may lead to retinal and choroidal neovascularization and vascular leakage contributing to vision loss.

PathophysiologyOverexpression of VEGF can result in retinal and choroidal neovascularization and vascular leakage, causing macular edema, exudation, and vision impairment or loss.

Clinical relevanceIntravitreal VEGF inhibitors are highly effective at reducing ocular neovascularization, macular edema, and exudation related to VEGF-driven retinal disorders.

Implication for therapyBecause VEGF drives neovascular disease and leakage, VEGF inhibitors (e.g., intravitreal agents) are used to treat neovascular AMD, DME, and other neovascular eye diseases.

Examples of related conditionsConditions associated with pathologic VEGF activity include neovascular AMD, diabetic macular edema, angioid streaks, iris neovascularization, neovascular glaucoma, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy, and presumed ocular histoplasmosis syndrome.