Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesOphthalmology/OptometryViva Health Plan Beovu Coverage Policy | OpenPayer
    Ask Trek AI about this page
    CurrentViva Health PlanPolicy IC-0497

    Beovu (brolucizumab-dbll) intravitreal therapy

    Customize your policy alerts

    Sign up for vivahealthplan Policy IC-0497 alerts

    Get alerted when Policy IC-0497 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs prior authorization, dosing, renewal, and billing requirements for intravitreal Beovu in adults with neovascular age-related macular degeneration or diabetic macular edema. It applies to providers requesting coverage under Viva Health Plan.

    Policy Summary
    PayerViva Health Plan
    PolicyBeovu (brolucizumab-dbll) intravitreal therapy
    Policy CodePolicy IC-0497
    Change TypeNo material clinical or coverage changes
    Effective DateN/A
    Last ReviewSep 1, 2026
    Next Review DateN/A
    Key ActionPrior authorization is required, with initial and renewal authorization valid for 12 months.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Covered indications
    12 monthsAuthorization period
    6 mgDose per affected eye
    18+Minimum member age
    12–84 daysMaintenance interval

    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.

    J0179Billing code

    Coverage Criteria

    Initial Approval Criteria

    Covered when all universal and indication-specific initial criteria are met.

    Initial therapy requirements

    • Universal requirements

      • Prerequisites

        • Bevacizumab prerequisite: The member has a contraindication, intolerance, or failure to a bevacizumab product before consideration of Beovu or another ophthalmic VEGF inhibitor.
        • Age: The member is at least 18 years of age.≥ 18 years
        • Safety: The member does not have an FDA-labeled contraindication to Beovu, including ocular or periocular infection, active intraocular inflammation, or hypersensitivity to brolucizumab or any Beovu excipients.
        • Concomitant therapy: Beovu will not be used concomitantly with another ophthalmic vascular endothelial growth factor (VEGF) inhibitor.

          Alternating treatment with other ophthalmic VEGF inhibitors is generally not permitted and is reviewed case by case.

        • Monitoring: Best corrected visual acuity (BCVA) is measured at baseline and periodically during treatment.

    • Definitive diagnosis

      • nAMD: The member has a definitive diagnosis of neovascular (wet) age-related macular degeneration (nAMD).
      • DME: The member has a definitive diagnosis of diabetic macular edema (DME).

    Coverage is not available when the member has an FDA-labeled contraindication to Beovu, including an ocular or periocular infection, active intraocular inflammation, or hypersensitivity to brolucizumab or any excipient in Beovu.

    Beovu must not be used concomitantly with another ophthalmic VEGF inhibitor. Alternating treatment regimens that use other ophthalmic VEGF inhibitors between Beovu treatments are generally not permitted and are reviewed case by case.

    Initial Beovu treatment is not medically necessary when the member is younger than 18 years, does not have a definitive diagnosis of neovascular (wet) age-related macular degeneration or diabetic macular edema, or has not demonstrated a contraindication, intolerance, or failure to a bevacizumab product before consideration of another ophthalmic VEGF inhibitor. Initial use also requires measured best corrected visual acuity at baseline and periodically during treatment, no FDA-labeled contraindication, and no concomitant ophthalmic VEGF inhibitor therapy.

    Continued Beovu treatment is not medically necessary when the member has not had a beneficial response, ongoing administration is not required for maintenance treatment, or unacceptable toxicity develops. Examples of unacceptable toxicity include endophthalmitis, retinal detachment, increased intraocular pressure, arterial thromboembolic events, retinal vasculitis, and retinal vascular occlusion. For an 8-week maintenance interval, the applicable disease-activity requirements must also be met after completion of the required loading doses: all 3 doses and treatment week 16 or later for nAMD, or all 5 doses and treatment week 28 or later for DME.

    Coding and Clinical Activity Criteria

    Covered HCPCS CodesHCPCSCovered
    J0179Injection, brolucizumab-dbll, 1 mg; 1 billable unit = 1 mg
    Covered Diagnosis CodesICD-10Covered
    E08.311Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
    E08.3211Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye
    E08.3212Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye
    E08.3213Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral
    E08.3219Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E08.3311Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye
    E08.3312Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye
    E08.3313Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
    E08.3319Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E08.3411Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye
    1–10 of 14
    1/2
    Covered Diagnosis Codes — Diabetes due to underlying conditionICD-10Covered
    E08.311Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
    E08.3211Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye
    E08.3212Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye
    E08.3213Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral
    E08.3219Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E08.3311Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye
    E08.3312Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye
    E08.3313Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
    E08.3319Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E08.3411Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye
    1–10 of 17
    1/2
    Covered Diagnosis Codes — Drug or chemical induced diabetesICD-10Covered
    E09.311Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
    E09.3211Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
    E09.3212Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
    E09.3213Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
    E09.3219Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E09.3313Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
    E09.3319Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E09.3411Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
    E09.3412Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
    E09.3413Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
    1–10 of 15
    1/2
    Covered Diagnosis Codes — Type 1 diabetesICD-10Covered
    E10.311Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
    E10.3211Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
    E10.3212Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
    E10.3213Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
    E10.3219Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E10.3311Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
    E10.3312Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
    E10.3313Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
    E10.3319Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E10.3411Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
    1–10 of 17
    1/2
    Covered Diagnosis Codes — Type 2 diabetesICD-10Covered
    E11.311Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
    E11.3211Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
    E11.3212Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
    E11.3213Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
    E11.3219Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E11.3311Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
    E11.3312Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
    E11.3313Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
    E11.3319Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E11.3411Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
    1–10 of 17
    1/2
    Covered Diagnosis Codes — Other specified diabetesICD-10Covered
    E13.311Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
    E13.3211Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
    E13.3212Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
    E13.3213Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
    E13.3219Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E13.3311Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
    E13.3312Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
    E13.3313Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
    E13.3319Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
    E13.3411Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
    1–10 of 17
    1/2
    Covered Diagnosis Codes — Exudative age-related macular degenerationICD-10Covered
    H35.3210Exudative age-related macular degeneration, right eye, stage unspecified
    H35.3211Exudative age-related macular degeneration, right eye, with active choroidal neovascularization
    H35.3212Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularization
    H35.3213Exudative age-related macular degeneration, right eye, with inactive scar
    H35.3220Exudative age-related macular degeneration, left eye, stage unspecified
    H35.3221Exudative age-related macular degeneration, left eye, with active choroidal neovascularization
    H35.3222Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularization
    H35.3223Exudative age-related macular degeneration, left eye, with inactive scar
    H35.3230Exudative age-related macular degeneration, bilateral, stage unspecified
    H35.3231Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization
    1–10 of 16
    1/2
    Medicare Part B jurisdiction and contractor referencemixed
    6, KApplicable State/US Territory: CA, HI, NV, AS, GU, CNMI; Contractor: Noridian Healthcare Solutions, LLC; Medicare Part B Administrative Contractor jurisdiction: Wellpoint Federal
    E (1)Applicable State/US Territory: AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ; Contractor: Noridian Healthcare Solutions, LLC
    5Applicable State/US Territory: KS, NE, IA, MO; Contractor: Wisconsin Physicians Service Insurance Corp (WPS)
    6Applicable State/US Territory: MN, WI, IL; Contractor: Wellpoint Federal
    H (4 & 7)Applicable State/US Territory: LA, AR, MS, TX, OK, CO, NM; Contractor: Novitas Solutions, Inc.
    8Applicable State/US Territory: MI, IN; Contractor: Wisconsin Physicians Service Insurance Corp (WPS)
    N (9)Applicable State/US Territory: FL, PR, VI; Contractor: First Coast Service Options, Inc.
    J (10)Applicable State/US Territory: TN, GA, AL; Contractor: Palmetto GBA
    M (11)Applicable State/US Territory: NC, SC, WV, VA (excluding below); Contractor: Palmetto GBA
    L (12)Applicable State/US Territory: DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA); Contractor: Novitas Solutions, Inc.
    1–10 of 12
    1/2
    nAMD visual acuity decline from baseline
    ConditionDecrease in best corrected visual acuity (BCVA) of ≥ 5 letters
    ComparisonCompared with baseline
    IndicationNeovascular age-related macular degeneration (nAMD)
    nAMD combined visual acuity and thickness activity
    Visual acuity thresholdDecrease in BCVA of ≥ 3 letters

    Provider Requirements and Denial Risks

    Prior Authorization

    12-Month Authorization Period

    Obtain prior authorization for Beovu® for an initial period of 12 months (365 days). Renewal authorization may be issued every 12 months (365 days) thereafter.

    • Initial authorization: 12 months (365 days).
    • Renewal authorization: every 12 months (365 days).
    Step Therapy

    Bevacizumab Prerequisite

    Before another ophthalmic vascular endothelial growth factor (VEGF) inhibitor is considered, document that the member has had the required prerequisite therapy with a bevacizumab product.

    • Bevacizumab is required as prerequisite therapy before consideration of another ophthalmic VEGF inhibitor.

    Policy Background

    Beovu (brolucizumab-dbll) is an intravitreal vascular endothelial growth factor inhibitor used for neovascular (wet) age-related macular degeneration and diabetic macular edema. Treatment begins with indication-specific loading doses and then transitions to maintenance dosing every 8–12 weeks; an 8-week interval may be used when specified disease-activity criteria are met. Ongoing treatment requires a beneficial response, monitoring of visual acuity, and assessment for serious ocular and systemic toxicity.

    Dosing and Regimen Definitions

    nAMD initial dosing
    Loading doses3 doses
    Administration intervalApproximately every 28 days
    IndicationNeovascular age-related macular degeneration (nAMD)
    DME initial dosing
    Loading doses5 doses
    Administration intervalApproximately every 42 days
    IndicationDiabetic macular edema (DME)
    Policy Summary
    PayerViva Health Plan
    PolicyBeovu (brolucizumab-dbll) intravitreal therapy
    Policy CodePolicy IC-0497
    Change TypeNo material clinical or coverage changes
    Effective DateN/A
    Last ReviewSep 1, 2026
    Next Review DateN/A
    Key ActionPrior authorization is required, with initial and renewal authorization valid for 12 months.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Clinical Activity CriteriaProvider Requirements and Denial RisksPolicy BackgroundDosing and Regimen Definitions
    Thickness thresholdCentral subfield thickness (CST) increase of ≥ 75 µm
    ComparisonBoth findings are compared with week 12
    nAMD visual acuity decline from week 12
    ConditionDecrease in BCVA of ≥ 5 letters due to neovascular AMD disease activity
    ComparisonCompared with week 12
    IndicationNeovascular age-related macular degeneration (nAMD)
    nAMD retinal-fluid activity
    FindingNew or worsening intraretinal cysts or fluid
    ComparisonCompared with week 12
    IndicationNeovascular age-related macular degeneration (nAMD)
    DME visual acuity and thickness activity
    Visual acuity thresholdDecrease in BCVA of ≥ 5 letters
    Thickness findingIncrease in central subfield thickness (CST)
    ComparisonBoth findings are compared with baseline
    Step Therapy

    Trial or Failure of Bevacizumab

    Document that the member has a contraindication, intolerance, or failure to a bevacizumab product before requesting Beovu® or another ophthalmic VEGF inhibitor.

    • Acceptable prerequisite history includes contraindication, intolerance, or failure of bevacizumab.

    Unsupported block type: documentation

    Unsupported block type: documentation

    Unsupported block type: documentation

    Unsupported block type: documentation

    Unsupported block type: documentation

    Unsupported block type: billing_rule

    Denial Risk

    Basic Eligibility Not Met

    Approval may be denied when basic eligibility requirements are not met, including failure to document the required age, definitive diagnosis, or other applicable initial criteria.

    • Member is younger than 18.
    • No definitive covered diagnosis is documented.
    • Required initial criteria are incomplete or not satisfied.
    Denial Risk

    FDA-Labeled Contraindication

    Approval may be denied when an FDA-labeled contraindication is present, including ocular or periocular infection, active intraocular inflammation, hypersensitivity to brolucizumab or its excipients, or another applicable contraindication.

    • Ocular or periocular infection.
    • Active intraocular inflammation.
    • Hypersensitivity to brolucizumab or any Beovu® excipient.
    Denial Risk

    Concurrent or Alternating VEGF Inhibitor Use

    Approval may be denied when Beovu® is used concurrently with another ophthalmic VEGF inhibitor or as part of an alternating VEGF-inhibitor regimen without permitted case-by-case approval.

    • No concomitant use with another ophthalmic VEGF inhibitor.
    • Alternating treatment regimens are generally not permitted.
    Denial Risk

    Unacceptable Toxicity

    Renewal may be denied when the member develops unacceptable toxicity from treatment, including listed ocular or systemic adverse events.

    • Examples include endophthalmitis, retinal detachment, increased intraocular pressure, arterial thromboembolic events, retinal vasculitis, or retinal vascular occlusion.
    Denial Risk

    Insufficient Response or Continued Need

    Renewal may be denied when the member does not demonstrate a beneficial response or when continued administration is not necessary for maintenance treatment of the condition.

    • No beneficial response, such as improvement in BCVA from baseline.
    • No documented ongoing need for maintenance treatment.
    • Insufficient clinical documentation supporting continued therapy or a shortened maintenance interval.
    Billing Rule

    Medicare Coverage Requirements

    Medicare Part B claims must comply with applicable coverage requirements, including relevant National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and related Local Coverage Articles (LCAs).

    • Confirm applicable Medicare Part B covered diagnosis and jurisdictional requirements.
    • Review the applicable Medicare Administrative Contractor guidance and claims-payment requirements.
    • Use the CMS Medicare Coverage Database to identify applicable NCD, LCD, or LCA documents.
    Alternating VEGF inhibitor regimen
    DefinitionTreatment with other ophthalmic vascular endothelial growth factor (VEGF) inhibitors between Beovu treatments
    Policy statusGenerally not permitted
    ReviewReviewed on a case-by-case basis