Payer PolicyActive
Vabysmo™ (faricimab-svoa intravitreal)
EVICORE-MEDICAL_DRUG-A552C6B2
EviCore by Evernorth
Effective: June 1, 2025
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Vabysmo (faricimab‑svoa intravitreal) is covered only for the FDA‑approved indications—neovascular (wet) AMD, diabetic macular edema (DME), and macular edema following retinal vein occlusion (RVO)—and is not covered for non‑FDA‑approved uses. Coverage requires administration by or under the supervision of an ophthalmologist, dosing of 6 mg intravitreal no more frequently than every 4 weeks, documentation of diagnosis and dosing, and authorization is granted for up to 12 months.
Coverage Criteria Preview
Key requirements from the full policy
"Neovascular (wet) age-related macular degeneration (nAMD)"
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