ModifiedAnthemPolicy CC-0072

Vascular Endothelial Growth Factor (VEGF) Inhibitors — Intravitreal anti‑VEGF agents

Clinical coverage criteria, step therapy, and quantity limits for intravitreal vascular endothelial growth factor (VEGF) antagonist drugs used to treat retinal diseases; applies to Anthem medical benefit plans and providers requesting prior authorization or coverage.

Policy Summary

PayerAnthem

PolicyVascular Endothelial Growth Factor (VEGF) Inhibitors — Intravitreal anti‑VEGF agents

Policy CodePolicy CC-0072

Change TypeMaterial revisions — added biosimilars, coding and step therapy updates

Effective DateMar 26, 2026

Next Review Date

Key ActionObtain prior authorization using the clinical criteria in this document; ensure dosing, indication, and step therapy requirements are documented.

SourceLink

POLICY UPDATE CHANGES

Added new ranibizumab biosimilar Nufymco (ranibizumab-leyk) to prior authorization criteria, step therapy, and quantity limits.

Added new bevacizumab biosimilar Jobevne (bevacizumab-nwgd) to bevacizumab criteria and quantity limits.

Added HCPCS J0177 for Eylea HD and separated Eylea HD from other aflibercept agents in coding and criteria.

Updated step therapy tables and quantity limits across multiple agent groups (including Vabysmo, Eylea, ranibizumab/bevacizumab groups).

Preferred and non-preferred agent lists were updated with effective dates 05/01/2026 for Commercial and Medicare benefits.

Eydenzelt was added to the non-preferred agents list effective 05/01/2026 for Commercial and Medicare benefits and appears in Medicaid listings.

MultipleVEGF inhibitors addressed

AMD, DME/DR, RVO, ROPCommon covered diagnoses

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Quantity limitsPer-eye dosing specified

05/01/2026Formulary status updated

3Benefit types listed

FLStates with Avastin precert required

Coverage Criteria for Intravitreal VEGF Antagonists

Agent-specific covered indications

Requests for individual agents may be approved when ALL of the following diagnosis-based conditions are met per the agent-specific list:

Vabysmo (faricimab-svoa): Individual has a diagnosis of established neovascular (wet) age-related macular degeneration OR diabetic macular edema (including DME with diabetic retinopathy of any severity) OR macular edema following retinal vein occlusion (RVO).

Avastin and bevacizumab biosimilars: Individual has one of the listed ocular diagnoses including diabetic macular edema (DME), proliferative or moderate-to-severe nonproliferative diabetic retinopathy (with or without DME), established neovascular (wet) AMD, macular edema following RVO, neovascular glaucoma, myopic choroidal neovascularization, other causes of choroidal neovascularization (e.g., angioid streaks, choroiditis, retinal dystrophies, trauma, pseudoxanthoma elasticum), radiation retinopathy, or retinopathy of prematurity as applicable.

Lucentis (ranibizumab) and ranibizumab biosimilars: Individual has a diagnosis of diabetic macular edema (including DME with diabetic retinopathy) OR proliferative or moderate-to-severe nonproliferative diabetic retinopathy (with or without DME) OR established neovascular (wet) AMD OR macular edema following RVO OR choroidal neovascularization associated with myopic degeneration OR radiation retinopathy.

Eylea (aflibercept) and aflibercept biosimilars: Individual has a diagnosis of diabetic macular edema (including DME with diabetic retinopathy) OR proliferative or moderate-to-severe nonproliferative diabetic retinopathy (with or without DME) OR established neovascular (wet) AMD OR macular edema following RVO OR retinopathy of prematurity.

Eylea HD (aflibercept HD): Individual has a diagnosis of neovascular (wet) age-related macular degeneration OR diabetic retinopathy OR diabetic macular edema OR macular edema following retinal vein occlusion.

Beovu (brolucizumab-dbll): Individual has a diagnosis of established neovascular (wet) age-related macular degeneration OR diabetic macular edema (including DME with diabetic retinopathy of any severity).

Non-preferred agent approval (step therapy) criteria

Non-preferred intravitreal VEGF antagonist requests may be approved when ONE of the following is met:

Current use: Individual has been on the requested non-preferred agent (continuation of therapy).

Failure or intolerance to preferred agent: Individual has had a trial and demonstrated inadequate response or intolerance to one preferred agent.

Regulatory/indication or special-case exceptions: The preferred agents are not FDA‑approved and lack accepted off‑label use for the prescribed indication while the requested non‑preferred agent is; OR Avastin is the sole preferred agent approvable for the diagnosis other than AMD; OR specific exceptions apply (e.g., individuals with a Susvimo implant requesting supplemental ranibizumab injections; or retinopathy of prematurity for certain aflibercept agents).

Agent quantity/frequency criteria

Covered when agent-specific per-eye dose and frequency limits are followed; Beovu has an allowed initiation option for AMD.

Per-eye dose limits: Each listed agent is limited to the specified mg per eye as shown in the policy (examples include: aflibercept 8 mg per eye for Eylea HD with approximately every 28 days +/- 7 days; standard aflibercept 2 mg per eye as specified; ranibizumab 0.3 mg or 0.5 mg per eye depending on indication; bevacizumab 1.25 mg per eye for ophthalmologic use; Beovu 6 mg per eye).See agent-specific thresholds

See coding/quantity limits sections for full agent list and limits.

Beovu initiation option: For Beovu (brolucizumab), may approve one 6 mg dose per eye monthly for the first three doses for age-related macular degeneration initiation as an alternative to every‑8‑week maintenance dosing.monthly x3 permitted for initiation

Covered when ALL of the following are met

Coverage is determined by agent-specific prior authorization criteria, step therapy status (preferred vs non-preferred), indication-specific ICD-10 matching, and quantity limits.

General prerequisites: Request must include a covered diagnosis code that matches one of the listed ICD‑10 ranges appropriate to the indication (examples: H35.3210‑H35.3293 for exudative AMD; E08/E09/E10/E11/E13 ranges for diabetic retinopathy with macular edema; H34.x ranges for RVO with macular edema).

See coding section for full ICD‑10 ranges.

Agent-specific step therapy and prior authorization: Approval depends on meeting the updated step therapy and prior authorization criteria for the requested agent or its biosimilar; preferred agent pathways and formulary status (updated effective dates noted in document history) affect whether a preferred agent must be tried first or a non‑preferred agent may be approved without trial.

Preferred/non-preferred lists updated (see Document History entries).

Requests for intravitreal injections of the listed agents may only be approved when the agent-specific diagnostic criteria are satisfied. Each agent has a defined set of covered ocular diagnoses (for example: Vabysmo — neovascular AMD, DME, or macular edema following RVO; Avastin group — DME, PDR/moderate-severe NPDR, wet AMD, RVO macular edema, neovascular glaucoma, myopic CNV, radiation retinopathy, or ROP as applicable; Lucentis/ranibizumab group and aflibercept group — similar diagnosis-based lists). Requests that do not meet the diagnosis requirements in the agent-specific sections may not be approved.

Inclusion or exclusion of procedure, diagnosis, or device codes in this policy is provided for informational purposes only and does not itself determine member coverage or provider reimbursement. Final coverage is determined by the member's contract benefits in effect at the time of service and supporting clinical documentation.

Certain codes and indications that were previously included in the policy have been removed historically; for example, radiation retinopathy-related ICD-10 codes were removed from some agent criteria in past updates. Review the Document History and current coding lists to verify which diagnoses and codes remain applicable.

Precertification requirements for repackaged bevacizumab (Avastin) vary by market. Avastin ocular precertification is required in Florida; a separate market list in the policy shows states where precertification is not required. Providers must confirm and obtain precertification where it is required before submission.

Use of any intravitreal VEGF antagonist for indications not included in that agent's specific coverage criteria is explicitly stated as not approvable. Approval is limited to the covered diagnoses listed under each agent's criteria.

None stated.

The procedural code CPT 67028 (intravitreal injection of a pharmacologic agent) is included in the policy for informational purposes when billed in conjunction with the intravitreal injection HCPCS for the specific agent. Inclusion of CPT 67028 does not by itself establish medical necessity — documentation must support the clinical indication and need for the specific agent billed.

Coding, Quantity Limits, and Diagnosis Codes

Provider Requirements and Prior Authorization

Prior Authorization

Quantity / Frequency Exceedance

Requests exceeding the policy quantity or frequency limits (per-eye dose limits or minimum interval between doses) may require prior authorization or be denied. Examples: more frequent than every 4 weeks for most agents, more frequent than every 8 weeks for Beovu maintenance, or doses exceeding the per‑eye milligram limits listed in the Quantity Limit section.

Per-eye quantity limits and minimum dosing intervals are in the "Vascular Endothelial Growth Factor (VEGF) Antagonists Quantity Limit" section.
Beovu: initiation may allow monthly dosing for the first three doses, but maintenance dosing every 8 weeks applies; requests for intervals or doses outside these parameters may need PA.
Requests for more frequent injections than allowed or for higher per‑eye doses may be denied if not justified with clinical documentation.

Documentation Required

Clinical Indication and Dosing Documentation

Document the ophthalmologic diagnosis that supports the requested intravitreal VEGF antagonist and include the indication-specific details (e.g., DME with diabetic retinopathy severity, nAMD, RVO subtype). Also document prior treatments, response or intolerance to preferred agents when applicable, and the exact dosing regimen intended (dose, eye laterality, and interval).

Background and Rationale

Overexpression of vascular endothelial growth factor (VEGF) contributes to neovascular retinal diseases including neovascular (wet) age-related macular degeneration, diabetic retinopathy and diabetic macular edema, and macular edema from retinal vein occlusion. Intravitreal anti-VEGF agents are first-line treatments for many of these conditions but carry procedure-related risks; biosimilars and interchangeable products are addressed in the policy with respect to indication extrapolation.

Definitions and Terms

Biosimilar / Interchangeable — Definitions

Biosimilar definitionBiosimilar products must be highly similar to the reference product with no clinically meaningful differences in safety, purity, and potency; they use the same MOA, route, dosage form and strength as the reference product.

Interchangeable definitionAn interchangeable product meets biosimilarity criteria and is expected to produce the same clinical result as the reference product; switching between the interchangeable and reference product does not increase risk of safety or diminished efficacy.

Extrapolation of indicationsFDA may allow extrapolation of indications for biosimilars based on sufficient scientific justification; factors include MOA, pharmacokinetics, biodistribution, and immunogenicity.

Loading/Initiation dosing

DefinitionLoading/Initiation dosing refers to a specified initial dosing schedule different from maintenance dosing (example below).

Policy Revision History and Changes

2026-03-01step_therapy_updateLatest

Step therapy table updates (operational) applied to intravitreal VEGF agents, reflecting recent selection reviews and table adjustments.

2026-02-20addition

Added ranibizumab biosimilar Nufymco (ranibizumab-leyk) to prior authorization criteria, step therapy, and quantity limits; added bevacizumab biosimilar Jobevne (bevacizumab-nwgd) to bevacizumab criteria and quantity limits; coding updates included HCPCS Q5160 and NOC codes C9399 and J3590 for Nufymco.

2025-12-08

Policy Summary

PayerAnthem

PolicyVascular Endothelial Growth Factor (VEGF) Inhibitors — Intravitreal anti‑VEGF agents

Policy CodePolicy CC-0072

Change TypeMaterial revisions — added biosimilars, coding and step therapy updates

Effective DateMar 26, 2026

Next Review Date

Key ActionObtain prior authorization using the clinical criteria in this document; ensure dosing, indication, and step therapy requirements are documented.

SourceLink

On This Page

Clinical documentation should match the policy diagnostic criteria for the requested agent (see Clinical Criteria sections for each agent).
When requesting a non-preferred agent, include records of trial and inadequate response or intolerance to preferred agents if claiming step therapy exception.
Billing notes: CPT/HCPCS entries and eye laterality should be supported by clinical notes; inclusion of codes in the policy is informational only.

Prior Authorization

Precertification Requirements for Avastin Ocular

Verify whether precertification (preauthorization) for Avastin ocular is required in the member's market before administering or billing. In markets where precertification is required, failure to obtain it may result in claims denial or payment delay.

Precertification NOT required in these markets: AR, CA, DC, GA, IN, IA, KY, LA, MD, MN, NE, NJ, NV, NY, NYW, OH, SC, TN, TX, VA, WA, WV, WI.
Precertification REQUIRED in these markets: FL (Florida).
If uncertain, contact the payer's prior authorization/precertification service for the member's state or plan.

Step Therapy

Non-Preferred Agent Step Therapy

Non-preferred intravitreal VEGF antagonists generally require step therapy documentation showing prior use of, or inadequate response/intolerance to, preferred agent(s) unless other specific exceptions apply.

Approval can be granted if the member is already on the requested non‑preferred agent (continuation).
Approval can be granted with documentation of trial and inadequate response or intolerance to one preferred agent.
Exceptions: if the preferred agents lack FDA approval or accepted off‑label use for the indication but the non‑preferred agent does; for certain diagnoses (e.g., ROP) or device situations (Susvimo implant requiring supplemental ranibizumab), specific agents may be approved per policy.
Check plan-specific preferred agent lists and effective dates (Commercial/Medicaid/Medicare) to determine which agents are preferred vs non-preferred.

Note

Step Therapy Updates and Preferred Agent Lists

Step therapy designations, preferred agent lists, and formulary status vary by benefit type and effective date; verify the member’s plan and the effective preferences before submitting a request. Plan-level preferred/non-preferred assignments may impose different pathways for approval.

Commercial (07/01/2025 and 05/01/2026) preferred and non‑preferred agent lists are published in the policy; confirm which date/version applies to the member.
Medicaid and Medicare preferred/non‑preferred agents vary by state and effective date — consult the policy tables for state‑specific designations.
Step therapy table updates and document history entries reflect recent changes (e.g., addition of Nufymco, Jobevne, edits to preferred lists); use the most current effective list when requesting approvals.

Note

Formulary / Step Considerations by Benefit

Formulary status and step/coverage rules may differ across Commercial, Medicaid, and Medicare benefits and by state. Confirm the member’s benefit type and market-specific rules (including any quantity limits, step therapy, or PA requirements) before submitting a request to avoid denials.

Commercial: see the policy's Commercial Medical Benefit preferred/non‑preferred listings and effective dates.
Medicaid: state‑level preferred agent assignments and dates are listed; some states have Avastin as preferred while others list many non‑preferred agents.
Medicare: check the Medicare Medical Benefit section for current preferred/non‑preferred listings and effective dates.

Beovu exampleFor Beovu (brolucizumab) initiation in AMD: may approve one 6 mg dose per eye monthly for the first three doses as an initiation option before transitioning to maintenance every 8 weeks.

Policy implicationInitiation/loading regimens require prior authorization when they differ from stated maintenance frequency limits.

Exudative age-related macular degeneration — ICD-10 range

ICD-10 range for exudative AMDH35.3210-H35.3293 (used to designate exudative/neovascular age-related macular degeneration for coverage and coding).

Use in coverage matchingThis ICD-10 range is referenced in agent-specific eligibility and coding requirements for AMD-related indications.

Document locationICD-10 ranges listed in the coding section and used as prerequisites for agent approval.

Diabetic retinopathy with macular edema — ICD-10 ranges

ICD-10 ranges (diabetes-related)E08.311-E08.3519; E09.311-E09.3519; E10.311-E10.3519; E11.311-E11.3519; E13.311-E13.3519 — ranges denote diabetic retinopathy with macular edema across diabetes types and are used to match agent indications.

ApplicationThese ranges are required to document covered diabetic retinopathy with macular edema when requesting intravitreal VEGF therapy.

Coding notePolicy coding section lists these ranges explicitly and ties them to agent eligibility and quantity limits.

Preferred Agents

Preferred agent list (reference)Preferred agents for the Commercial and Medicare benefits (effective dates in document history) include: Avastin, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Pavblu, Vabysmo.

Effective datesFormulary/preferred status updated with effective dates noted in document history (e.g., lists effective 07/01/2025 and updates effective 05/01/2026 in history).

Plan variationPreferred agent status may vary by benefit and date; consult the plan-specific formulary for current status.

Non-Preferred Agents

Non-preferred agent list (reference)Non-preferred agents identified in document history and formulary listings include Ahzantive, Beovu, Enzeevu, Opuviz, Yesafili, Eydenzelt (added effective 05/01/2026).

Impact on step therapyNon-preferred designation triggers step therapy requirements (trial of a preferred agent or documented intolerance/insufficient response).

Document history additionsDocument history records additions and step therapy table updates affecting non-preferred status across review dates.

Added Eylea HD indication for retinal vein occlusion and introduced quantity limits for Eylea HD for RVO; updated RVO criteria and Eylea HD quantity limits and performed step therapy/table updates.

2025-11-14addition

Added Eylea biosimilar Eydenzelt (aflibercept-boav) to prior authorization criteria and quantity limits; separated Eylea HD from other aflibercept agents with coding (added NOC J3590 and C9399) and updated Beovu dosage form listings.

2025-12-01step_therapy_update

Step therapy table updates recorded (operational changes to preferred/non-preferred designations and related pathways).

2024-04-01coding_addition

Added HCPCS J0177 for Eylea HD (aflibercept) to coding for intravitreal injections.

2023-11-17addition_and_coding

Updated Vabysmo criteria (FDA label expansion to include macular edema following RVO), added quantity limits for that indication, and added ICD-10 RVO codes; earlier Eylea HD coding (C9161 then J0177) noted in history.

Step therapy tables and preferred/non-preferred agent lists have been updated multiple times as reflected in the Document History. These operational updates affect which agents are designated preferred or non-preferred and therefore the required step therapy pathways and prior-authorization expectations for providers.

Requests may be denied if prior authorization, step therapy, or quantity limit criteria for newly added biosimilars or agent-specific updates are not met. Recent Document History entries note additions such as new ranibizumab and bevacizumab biosimilars and related PA/quantity-limit updates that could affect approvals.

Formulary and step therapy designations are effective-dated and may differ by benefit type. The policy lists preferred and non-preferred agents with effective dates (for example, formulary updates effective 05/01/2026) for Commercial and Medicare benefits; providers should follow plan-specific formulary rules and the effective dates when determining step therapy requirements.