CurrentViva Health PlanPolicy IC-0876

Intravitreal Lytenava (bevacizumab-vikg) for neovascular age-related macular degeneration

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This policy governs prior authorization, dosing, coverage criteria, renewal, and billing for intravitreal Lytenava in adult members with neovascular (wet) age-related macular degeneration for Viva Health Plan commercial and Medicare Advantage provider-administered drug coverage.

Policy Summary

PayerViva Health Plan

PolicyIntravitreal Lytenava for neovascular age-related macular degeneration

Policy CodePolicy IC-0876

Change TypeNo material change

Effective DateN/A

Last ReviewSep 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization documentation showing a definitive wet age-related macular degeneration diagnosis and prior contraindication, intolerance, or failure of at least one compounded ophthalmic bevacizumab product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsInitial and renewal authorization

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CurrentViva Health PlanPolicy IC-0876

Intravitreal Lytenava (bevacizumab-vikg) for neovascular age-related macular degeneration

Customize your policy alerts

Sign up for vivahealthplan Policy IC-0876 alerts

Get alerted when Policy IC-0876 changes without checking for updates manually.

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Policy Summary

PayerViva Health Plan

PolicyIntravitreal Lytenava for neovascular age-related macular degeneration

Policy CodePolicy IC-0876

Change TypeNo material change

Effective DateN/A

Last ReviewSep 1, 2026

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsInitial and renewal authorization

1.25 mg monthlyRecommended nAMD dose

10Covered diagnosis codes

Coverage Criteria

Initial therapy

Covered for initial authorization when all criteria are met:

Initial approval

Universal criteria: The member does not have any FDA-labeled contraindications to the requested agent, including ocular or peri-ocular infection, active intraocular inflammation, or hypersensitivity to any bevacizumab product; intraocular pressure will be monitored before and after each intravitreal injection and managed appropriately; therapy will not be used concomitantly with other ophthalmic VEGF inhibitors; the member has a contraindication, intolerance, or failure to at least one compounded ophthalmic bevacizumab product before Lytenava is considered; and best corrected visual acuity (BCVA) is measured at baseline and periodically during treatment.At least one compounded ophthalmic bevacizumab product must be contraindicated, not tolerated, or have failed
Use in an alternating treatment regimen with another ophthalmic VEGF inhibitor is generally not permitted and is reviewed case by case.
Indication-specific criterion: The member has a definitive diagnosis of neovascular (wet) age-related macular degeneration (nAMD).Definitive nAMD diagnosis
The diagnosis should identify the affected eye and applicable disease stage or choroidal neovascularization status.

Continuation or renewal therapy

Renewal is available when all criteria are met:

Renewal therapy

Continued eligibility: The universal and indication-specific initial approval criteria remain satisfied.Criteria continue to be met
Safety and response: No unacceptable toxicity from Lytenava is present, and the member has had a beneficial response to therapy, such as improvement in BCVA from baseline.Beneficial response documented from baseline
Ongoing necessity: Continued administration is necessary for maintenance treatment of the condition.Maintenance treatment remains medically necessary

Use of Lytenava is excluded when the member has an FDA-labeled contraindication to the requested agent, including ocular or peri-ocular infection, active intraocular inflammation, or hypersensitivity to any bevacizumab product.

Lytenava must not be used concomitantly with other ophthalmic vascular endothelial growth factor (VEGF) inhibitors. Use in an alternating treatment regimen with another ophthalmic VEGF inhibitor is generally not permitted and requires case-by-case review.

Continuation is excluded when unacceptable toxicity from the drug is present, including endophthalmitis, retinal detachment, severe increases in intraocular pressure, or arterial thromboembolic events.

Coding and Utilization Parameters

HCPCS CodeHCPCS

J3590

Unclassified biologics

NDCNDC

82491-0025-xx

Lytenava 1.25 mg solution in a single-dose vial for injection

Covered Diagnosis CodesICD-10Covered

H35.3210	Exudative age-related macular degeneration, right eye, stage unspecified
H35.3211	Exudative age-related macular degeneration, right eye, with active choroidal neovascularization
H35.3212	Exudative age-related macular degeneration, right eye, with inactive choroidal neovascularization
H35.3213	Exudative age-related macular degeneration, right eye, with inactive scar
H35.3220	Exudative age-related macular degeneration, left eye, stage unspecified
H35.3221	Exudative age-related macular degeneration, left eye, with active choroidal neovascularization
H35.3222	Exudative age-related macular degeneration, left eye, with inactive choroidal neovascularization
H35.3223	Exudative age-related macular degeneration, left eye, with inactive scar
H35.3230	Exudative age-related macular degeneration, bilateral, stage unspecified
H35.3231	Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization

1–10 of 16

1/2

Compounded Ophthalmic Bevacizumab Examplesmixed

J9035	Example code for a compounded ophthalmic bevacizumab product
5107	Example code for a compounded ophthalmic bevacizumab product
Q5118	Example code for a compounded ophthalmic bevacizumab product
Q5126	Example code for a compounded ophthalmic bevacizumab product
Q5129	Example code for a compounded ophthalmic bevacizumab product
Q5160	Example code for a compounded ophthalmic bevacizumab product
C9257	Example code for a compounded ophthalmic bevacizumab product

Maximum dose limit

Maximum dose2.5 mg per 28 days, based on administration to both eyes

nAMD dose

Recommended dose for nAMD1.25 mg intravitreally into the affected eye(s) once monthly (approximately 28 days)

Minimum age

Minimum ageAt least 18 years of age

Initial authorization duration

Provider Requirements and Decision Points

Prior Authorization

Initial Prior Authorization Required

Prior authorization is required for Lytenava (bevacizumab-vikg) intravitreal therapy. Initial authorization is available for 12 months (365 days) when the member is at least 18 years old, all universal criteria are met, and the requested use is for neovascular (wet) age-related macular degeneration (nAMD).

Initial authorization validity: 12 months (365 days).
Member must be 18 years of age or older.
Requested indication: definitive diagnosis of neovascular (wet) age-related macular degeneration (nAMD).
Therapy must meet all applicable universal criteria, including the required compounded bevacizumab prerequisite.

Prior Authorization

Annual Renewal

Renewal authorization may be provided every 12 months (365 days) when the member continues to meet universal and indication-specific criteria, has no unacceptable toxicity, and continues to benefit from treatment.

Clinical Background

Lytenava (bevacizumab-vikg) is administered by intravitreal injection for neovascular (wet) age-related macular degeneration (nAMD), a form of age-related macular degeneration involving abnormal choroidal blood vessel growth and leakage. The policy dose is 1.25 mg intravitreally into the affected eye or eyes approximately every 28 days. Intraocular pressure is monitored before and after each injection, and best corrected visual acuity is measured at baseline and periodically during treatment.

Definitions and Abbreviations

nAMD

nAMDNeovascular (wet) age-related macular degeneration

BCVA

BCVABest corrected visual acuity, measured at baseline and periodically during treatment

VEGF

VEGFVascular endothelial growth factor

Policy Summary

PayerViva Health Plan

PolicyIntravitreal Lytenava for neovascular age-related macular degeneration

Policy CodePolicy IC-0876

Change TypeNo material change

Effective DateN/A

Last ReviewSep 1, 2026

Next Review DateN/A

SourceLink

On This Page

Initial authorization12 months (365 days)

Renewal authorization duration

Renewal authorization12 months (365 days) thereafter

Renewal interval: 12 months (365 days).

Document continued clinical eligibility, safety, and the necessity of ongoing treatment.

Step Therapy

Compounded Bevacizumab Prerequisite

Before Lytenava can be considered, the member must have a contraindication, intolerance, or failure to at least one compounded ophthalmic bevacizumab product.

The prerequisite applies to at least one compounded ophthalmic bevacizumab product, such as J9035, 5107, Q5118, Q5126, Q5129, Q5160, or C9257.

Documentation Required

Diagnosis and Affected-Eye Documentation

Submit documentation supporting the definitive nAMD diagnosis, the affected eye or eyes, and the requested intravitreal application of Lytenava.

Document the definitive diagnosis of neovascular (wet) age-related macular degeneration (nAMD).
Identify the affected eye or eyes and the requested treatment application.

Documentation Required

Safety and Visual Monitoring

Screen for FDA-labeled contraindications and document required monitoring before and during treatment. Do not use Lytenava concomitantly with other ophthalmic VEGF inhibitors; alternating regimens are generally not permitted and are reviewed case by case.

Confirm no ocular or peri-ocular infection, active intraocular inflammation, or hypersensitivity to any bevacizumab product.
Monitor intraocular pressure before and after each intravitreal injection and manage it appropriately.
Measure best corrected visual acuity (BCVA) at baseline and periodically during treatment.

Documentation Required

Prior Compounded Bevacizumab History

Document the member's prior compounded bevacizumab experience before submitting the Lytenava request, including the product used and the clinical basis for the contraindication, intolerance, or failure.

Identify the prior compounded ophthalmic bevacizumab product or products.
Describe the documented contraindication, intolerance, or inadequate treatment response that supports moving to Lytenava.

Prior Authorization

Renewal Clinical Response

For renewal, document that the member continues to meet all universal and indication-specific criteria, has no unacceptable drug toxicity, and has experienced a beneficial response requiring continued maintenance treatment.

Document continued eligibility for the covered indication and universal criteria.
Report absence of unacceptable toxicity, including endophthalmitis, retinal detachment, severe increases in intraocular pressure, or arterial thromboembolic events.
Document beneficial response, such as improvement in BCVA from baseline, and the need for continued administration.

Denial Risk

Initial Approval Requirements Not Met

Initial authorization may be denied when the member does not meet the age requirement, lacks the covered diagnosis, fails any universal criterion, or does not satisfy the compounded bevacizumab prerequisite.

Member is younger than 18 years.
No definitive diagnosis of neovascular (wet) age-related macular degeneration (nAMD).
Any FDA-labeled contraindication, prohibited concomitant ophthalmic VEGF-inhibitor use, or missing required monitoring.
No documented contraindication, intolerance, or failure to a qualifying compounded ophthalmic bevacizumab product.

Denial Risk

Renewal Criteria Not Met

Renewal may be denied when the member no longer meets universal or indication-specific criteria, develops unacceptable toxicity, or lacks documentation of beneficial response and continued treatment necessity.

Universal or indication-specific criteria are no longer met.
Unacceptable toxicity is present.
No documented beneficial response or medical necessity for continued maintenance treatment.

Denial Risk

Dosing Limit Exceeded

Requests or claims exceeding the maximum allowed dose may be denied or rejected. The dosing limit is based on administration to both eyes.

Maximum: 2.5 mg per 28 days.
Limit applies to the combined administration to both eyes.