Beovu (brolucizumab-dbll)

Beovu is a human vascular endothelial growth factor (VEGF) inhibitor indicated for the treatment of Neovascular (Wet) Age-Related Macular Degeneration (AMD).

I. Criteria for Initial Approval

Beovu will be considered for coverage when ALL of the criteria below are met, confirmed with supporting medical documentation.

● Patient is at least 18 years of age. ● Patient has a definitive diagnosis of Neovascular (Wet) AMD. ● Beovu will be prescribed and administered by an Opthamologist. ● Patients must have had an inadequate response to an adequate trial of, or contraindication or intolerance to, bevacizumab (Avastin) prior to initiating therapy with Beovu. ● Patient has baseline measurement of the best corrected visual acuity (BCVA). ● Patient is free of any active intraocular inflammation or ocular/periocular infections. ● Therapy will not be used with other ophthalmic VEGF inhibitors (e.g., aflibercept, ranibizumab, pegaptanib, bevacizumab). ● Females of reproductive potential should use contraception during treatment with Beovu, and for at least one month after the last dose when stopping treatment with Beovu.

II. Criteria for Continuation of Therapy

All of the criteria for initial therapy (in Section I.) must be met; AND ● Absence of unacceptable toxicity from the drug. ● Documentation that the patient has had a beneficial response to therapy (e.g., improvement in the baseline BCVA). ● Documentation that continued administration is necessary for the maintenance treatment of the patient’s Neovascular (Wet) AMD.

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III. Dosing/Administration Beovu must be administered according to the current FDA labeling guidelines for dosage and timing. The recommended dosing is as follows:

● 6 mg (0.05 mL of 120 mg/mL solution) of Beovu administered by intravitreal injection monthly (approximately every 25-31 days) for the first three doses, followed by 6 mg (0.05 mL) by intravitreal injection once every 8 to 12 weeks.

IV. Length of Authorization For initial therapy Beovu will be authorized for 6 months when criteria for initial approval are met. Continuing therapy with Beovu will be authorized for 12 months.

V. Billing Code/Information J0179 – Injection, brolucizumab-dbll, 1 mg; 1 mg = 1 billable unit.

Prior authorization of benefits is not the practice of medicine nor the substitute for the independent medical judgment of a treating medical provider. The materials provided are a component used to assist in making coverage decisions and administering benefits. Prior authorization does not constitute a contract or guarantee regarding member eligibility or payment. Prior authorization criteria are established based on a collaborative effort using input from the current medical literature and based on evidence available at the time.

Approved by MDH Clinical Criteria Committee: 12/7/2020 Last Reviewed Date: 12/7/2020

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