Description

Brolucizumab (Beovu^®) is a humanized monoclonal single-chain variable fragment (scFv) that binds and inhibits vascular endothelial growth factor A (VEGF-A). VEGF is a signal protein that promotes the growth of new blood vessels from pre-existing vessels.

Policy

Coverage of these drugs is provided when the criteria below are met and, for nonpreferred products, there has been a trial and failure of TWO preferred therapies. (Exceptions to the preferred therapy in the policy includes pregnancy, breastfeeding, 17 years old and younger, members who previously attempted to switch agents and did not respond to therapy or had adverse event, and members whose disease is uncontrolled). Preferred medication are Byooviz, Cimerli, Lucentis, and Vabysmo.

Initial Criteria:

• Member has one of the following diagnoses:
  • Neovascular (wet) age-related macular degeneration (nAMD)
  • Diabetic macular edema (DME)
• Prescribed by or in consultation with an ophthalmologist
• Member does not have ocular or periocular infection
• Member does not have active intraocular inflammation

Auth duration: 6 months

Reauthorization Criteria

• Documentation of positive clinical response to therapy (such as improvement in best corrected visual acuity (BCVA) compared to baseline, stable vision)

Auth duration: 12 months

References

1. FDA. Highlights of Prescribing Information Beovu® (brolucizumab-dbll). (2019) Revised 12/2022. Available at: <http://www.accessdata.fda.gov> (accessed on February 23, 2023).

2. Dugel PU, Koh A, Ogura Y, et al. HAWK and HARRIER: Phase 3, multicenter, randomized, double-masked trials of brolucizumab for neovascular age-related macular degeneration. Opthamology. Jan 2020; 127(1):72-84. PMID 30986442

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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