Payer PolicyActive
Brolucizimab (Beovu®)
EVICORE-MEDICAL_DRUG-F981FC21
EviCore by Evernorth
Effective: October 1, 2021
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Beovu (brolucizumab-dbII) is covered only for FDA‑approved Neovascular (Wet) AMD and specified compendial off‑label neovascular ophthalmic conditions (diabetic retinopathy, neovascular glaucoma, retinopathy of prematurity, sickle cell neovascularization, and choroidal neovascular conditions) and is not covered for unlisted uses. Coverage requires intravitreal administration by or under the supervision of an ophthalmologist, adherence to the recommended dosing (6 mg monthly ×3 then 6 mg every 8–12 weeks), and is authorized for a 12‑month approval period.
Coverage Criteria Preview
Key requirements from the full policy
"Retinopathy of prematurity (listed as an approved off-label compendial use / other neovascular ophthalmic condition)."
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