Traditional MedicarePrior AuthMedium impact
Vabysmo® (faricimab-svoa) (Revised)
Humana·FL, KY, SC · Ophthalmology·Medicaid
Effective date
Mar 25, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Vabysmo (faricimab-svoa) prior authorization policy effective March 25, 2026, covering three retinal indications across Medicare, Florida Medicaid, Kentucky Medicaid, and South Carolina Medicaid. The policy maintains step therapy requirements (bevacizumab contraindication/intolerance or failed prior therapy) for all three indications, with a critical exception: Florida Medicaid requests are exempt from the bevacizumab step therapy requirement (^Does not apply to Florida Medicaid requests). This is a revised policy that supersedes previous guidance.
Action Required
By March 25, 2026: Billing and prior authorization teams must update systems and workflows to reflect the revised Vabysmo policy. CRITICAL: For Florida Medicaid claims, remove the bevacizumab step therapy requirement from prior authorization checks—Florida Medicaid members may receive Vabysmo without documented bevacizumab failure. For Medicare, Kentucky Medicaid, and South Carolina Medicaid, maintain the existing step therapy requirement (contraindication/intolerance to bevacizumab OR prior bevacizumab failure with provider attestation). Update prior authorization templates and decision trees to flag Florida Medicaid as exempt from step therapy. Ensure claims submitted before 3/25/2026 use old policy; claims on/after 3/25/2026 use revised policy. Train clinical review staff and billing personnel on state-specific requirements to prevent incorrect denials (Kentucky/South Carolina) or inappropriate approvals (Florida). Verify with Humana PAL portal for any claim code updates.