Payer PolicyActive
Beovu (brolucizumab)
EVICORE-MEDICAL_DRUG-C6766323
EviCore by Evernorth
Effective: October 1, 2023
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Beovu (brolucizumab) is covered only for FDA‑approved indications (neovascular/wet AMD and diabetic macular edema) and specified compendial off‑label neovascular ophthalmic uses; other indications are not covered. Authorization is up to 12 months, must be administered by or under an ophthalmologist, requires adherence to indication‑specific dosing (AMD/other neovascular eye disease: 6 mg monthly ×3 then every 8–12 weeks; DME: 6 mg every ~6 weeks ×5 then every 8–12 weeks), and documentation of diagnosis, injection dates/doses/route, and medical necessity.
Coverage Criteria Preview
Key requirements from the full policy
"Neovascular (Wet) Age-related Macular Degeneration (AMD)"
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