CurrentAvMedPolicy N/A

Aflibercept (Eylea) for Retinopathy of Prematurity — Prior Authorization Coverage Criteria

Prior authorization form and clinical criteria for coverage of Eylea (aflibercept J0177) for treatment of Retinopathy of Prematurity (ROP) in premature infants; intended for AvMed providers requesting outpatient drug approval.

Policy Summary

PayerAvMed

PolicyAflibercept (Eylea) for Retinopathy of Prematurity — Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit a medical prior authorization request with required clinical criteria and supporting documentation (including ROP staging and birth history) for approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

0.4 mgDose

10 daysMin interval

3 moInitial auth

≤32 wkMax GA

≤1500 gMax birth wt

Coverage Criteria for Aflibercept (Eylea) — Retinopathy of Prematurity

Initial Authorization Criteria

Covered when ALL of the following are met

Provider qualifications: Provider is an Ophthalmologist and specializes in the diagnosis of Retinopathy of Prematurity

Diagnosis: Member has a definitive diagnosis of Retinopathy of Prematurity

Prematurity criteria (one required): Member is a premature infant with ONE of the following: maximum gestational age at birth ≤ 32 weeks OR birth weight ≤ 1500 ggestational age ≤ 32 weeks; birth weight ≤ 1500 g

Staging documentation:

Policy Summary

PayerAvMed

PolicyAflibercept (Eylea) for Retinopathy of Prematurity — Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit a medical prior authorization request with required clinical criteria and supporting documentation (including ROP staging and birth history) for approval.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing Codes, NDCs, and Injection Limits

Requested Drug HCPCSHCPCSCovered

J0177

Aflibercept injectable — Eylea (aflibercept) for Retinopathy of Prematurity (ROP) (Medical)

Required NDC/FormulationNDCCovered

NDC: 61755-0005-02

Single-dose vial kit — only applicable formulation for ROP; do NOT use the pre-filled syringe for the treatment of ROP

inv-07: Initial authorization injections — Up to 3 injections per eye over 3 months

Authorization durationInitial authorization: up to 3 injections per eye over a 3-month period

Dose per injectionRecommended dosage: 0.4 mg (0.01 mL or 10 microliters) via intravitreal injection

Minimum intervalMinimum interval between doses in the same eye: at least 10 days

inv-08: Reauthorization injections — Up to 3 additional injections per eye over 3 months

Reauthorization durationReauthorization: up to 3 additional injections per eye over a 3-month period

Documentation requiredProvider must submit current infant ROP location & classification (Zone & Stage) to assess improvement

Indication for re-initiationReauthorization supported if member has recurrent ROP requiring re-initiation of treatment

Provider Requirements and Submission Guidance

Prior Authorization

Prior authorization required for Eylea (J0177)

Prior authorization is required for Eylea (aflibercept) for Retinopathy of Prematurity (J0177). Complete and submit the medical prior authorization request form with the required clinical criteria and supporting documentation for approval.

Submit the completed Medical Prior Authorization/Step-Edit Request form (prescribing physician signature required).
Indicate drug requested: Eylea (aflibercept) — ROP (J0177).
Check all applicable clinical criteria on the form for initial authorization or reauthorization.

Step Therapy

Samples do not meet preauthorization/step criteria

Use of samples to start therapy does not satisfy step-edit or preauthorization requirements; AvMed will verify prior therapies through pharmacy paid claims or submitted chart notes.

Do not rely on samples to meet prior authorization or step therapy edits.
Provide documentation of prior treatments (pharmacy claims or chart notes) when applicable.

Documentation Required

Submit supporting clinical documentation

Provider must submit documentation supporting each checked clinical criterion on the form; include lab results, diagnostic tests, and chart notes. For ROP, include infant ophthalmology notes and ROP imaging and the infant ROP location & classification per International Classification of ROP (2005) where available.

Include infant ROP location & classification (Zone and Stage or AP-ROP) and any relevant imaging.
Attach lab results, diagnostic reports, and chart notes that substantiate each checked criterion.

Denial Risk

Incomplete or illegible submissions risk delay or denial

Authorization may be delayed or denied if the submission is incomplete, incorrect, or illegible; missing required information such as diagnosis, gestational age, or weight can prevent approval.

Ensure all required fields (diagnosis, ICD code if applicable, weight and date weight obtained, dosing schedule) are completed and legible.
Incomplete or missing documentation (lab results, diagnostics, chart notes) may result in denial or processing delays.

Background — Retinopathy of Prematurity (ROP)

Retinopathy of Prematurity (ROP) is a disease of premature infants characterized by abnormal retinal vascular development that can progress through defined zones and stages. Management may require intravitreal anti-VEGF injections such as aflibercept; the form references the International Classification of ROP (2005) for documenting Zone and Stage (including Aggressive Posterior ROP (AP-ROP)). The recommended intravitreal dosage referenced is 0.4 mg per injection, injections may be given bilaterally the same day, and the minimum interval between doses in the same eye is 10 days.

Definitions and Key Terms

inv-14: Aggressive Posterior ROP (AP-ROP)

DefinitionAggressive Posterior Retinopathy of Prematurity (AP-ROP) is a subtype of ROP to be reported with zone/stage when present

Form reportingAP-ROP has a dedicated field on the authorization form: "Aggressive Posterior Retinopathy of Prematurity (AP-ROP), Zone/Stage"

Use in assessmentAP-ROP should be included in submitted infant ROP location & classification per International Classification ROP (2005)

inv-15: Single-dose vial kit — single-dose vial required; pre-filled syringe must not be used

Required formulationTreatment for this indication is ONLY applicable to the single-dose vial kit (NDC: 61755-0005-02)

Pre-filled syringe restrictionDo NOT use the pre-filled syringe for the treatment of ROP

Relevant dosing noteRecommended intravitreal dosage and formulation details are specified on the form (0.4 mg per injection)