MedicaidPrior AuthMedium impact
Vabysmo® (faricimab-svoa) (Revised)
Humana·LA · Ophthalmology·Medicaid
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
Humana Medicaid Louisiana revised its prior authorization policy for Vabysmo (faricimab-svoa) effective January 1, 2023, with a revision date of March 25, 2026. The policy requires prior authorization for three retinal conditions (wet AMD, DME, and RVO-related macular edema), with approval contingent on documented contraindication/intolerance to bevacizumab OR failure to demonstrate positive clinical response to prior bevacizumab therapy. Billing teams must verify all three criteria are met and documented before claim submission to avoid denials.
Action Required
Before submitting any Vabysmo claims to Humana Medicaid Louisiana: (1) Billing team must verify that prior authorization has been obtained through Humana's PAL system (www.humana.com/PAL) before claim submission; (2) Providers must document in the clinical record: (a) diagnosis of neovascular wet AMD, Diabetic Macular Edema, or Macular Edema following Retinal Vein Occlusion, AND (b) either documented contraindication/intolerance to bevacizumab OR attestation that the member received prior bevacizumab therapy without demonstrating positive clinical response (defined as improvement/maintenance in BCVA, visual field improvement, or reduction in vision decline rate); (3) Front desk/authorization staff must ensure documentation of bevacizumab trial failure includes specific clinical outcomes (visual acuity measurements or visual field results); (4) Billing team must reference applicable medically billed claim codes via Humana's PAL system. Claims submitted without prior authorization or missing required clinical documentation will be denied. This is a Louisiana Medicaid-specific policy and does not apply to other states or plan types.