Intravitreal VEGF inhibitor coverage and prior authorization policy
Customize your policy alerts
Sign up for Blue Cross Blue Shield - Iowa Policy 09.03.12 alerts
Get alerted when Policy 09.03.12 changes without checking for updates manually.
Monitor payer policy activity
Defines medical necessity, preferred and non-preferred VEGF inhibitor products, and prior authorization requirements for non-preferred intravitreal VEGF agents for members covered by Blue Cross Blue Shield - Iowa.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Coverage and prior authorization criteria
Preferred products are considered medically necessary without prior authorization for listed ophthalmic indications. Non-preferred/targeted products require prior authorization when the Preferred Drug Plan Design applies.
Indications include neovascular (wet) AMD; macular edema following retinal vein occlusion (BRVO and CRVO); diabetic macular edema; proliferative diabetic retinopathy as an adjunct to photocoagulation or vitrectomy; diabetic retinopathy; retinopathy of prematurity; and choroidal neovascularization secondary to angioid streaks, central serous chorioretinopathy, choroidal rupture or trauma, multifocal choroiditis, pathologic myopia, presumed ocular histoplasmosis syndrome, uveitis, and idiopathic choroidal neovascularization.
Non-preferred initial approval conditions
- Option 1: Member has documented inadequate response or an intolerable adverse event to one of the preferred products (Byooviz, Lucentis, Eylea, Eylea HD, Vabysmo).
Chart notes documenting inadequate response or intolerance must be submitted.
- Option 2: Member is currently receiving therapy with the non-preferred product (excluding samples or manufacturer patient assistance) and is experiencing a positive therapeutic outcome.
Ongoing benefit must be documented in the medical record.
Documentation of prior response to intravitreal VEGF injections is required for Susvimo requests.
Coverage for these non-preferred products is contingent on meeting the Preferred Drug Plan Design criteria and required documentation.
Ongoing clinical benefit should be documented to support continuation approvals.
This policy’s applicability is subject to the member’s specific contract. Benefits are contract-dependent and exclusions, limitations, or exceptions may apply; individual member benefits must be verified. The policy may not apply to Federal Employee Program (FEP) members — benefit determinations for FEP are made by the Federal Employee Program and not by this policy.
The policy identifies certain intravitreal VEGF agents that do not require prior authorization and are considered medically necessary for listed ophthalmic indications. Bevacizumab is noted as the best-value VEGF inhibitor, supported by peer-reviewed literature, and does not require prior authorization. Additionally, the following preferred products — Lucentis (ranibizumab), Eylea (aflibercept), Eylea HD (aflibercept), Byooviz (ranibizumab‑nuna), and Vabysmo (faricimab) — are considered medically necessary without prior authorization when used for the covered indications enumerated in the policy (for example, neovascular AMD, DME, RVO-related macular edema, proliferative DR adjunctive therapy, ROP, and multiple causes of choroidal neovascularization).
Prior Authorization, Documentation, and Provider Requirements
Prior authorization required for non-preferred VEGF products
Prior authorization is required for non-preferred/targeted intravitreal VEGF products (Beovu, Cimerli, Pavblu, Susvimo). Submit the required clinical documentation listed in the policy to initiate review.
- Applies to Beovu, Cimerli, Pavblu, and Susvimo.
- Provider must submit documentation described under "Required Documentation" to initiate prior authorization.
Policy history and references (no new PA steps)
These reference sections provide policy history and supporting citations but do not add additional operational prior authorization instructions beyond those in the main prior authorization criteria.
- Policy history and references (last review Oct 2025; effective Jan 1, 2026) are listed here.
Initial approval requires failure or intolerance to a preferred product
Under the Preferred Drug Plan Design, initial approval for a non-preferred product is allowed only when the member has a documented inadequate response or intolerable adverse event to a preferred product, or is currently receiving the non-preferred product with documented positive therapeutic outcome.
- Preferred products referenced include Byooviz, Lucentis, Eylea, Eylea HD, and Vabysmo.
- Current use of a non-preferred product qualifies only if not obtained as samples or via manufacturer patient assistance and there is documented benefit.
No specified stepwise sequencing
The policy does not specify a required stepwise sequencing of agents beyond the Preferred Drug Plan Design criteria; no explicit step therapy algorithm is provided in the reference sections.
- Clinicians should follow the Preferred Drug Plan Design requirements for exceptions; no ordered agent sequence is mandated by this policy.
Submit chart notes documenting inadequate response or intolerable adverse event to preferred products
To initiate prior authorization for a non-preferred product, submit chart notes documenting an inadequate response to or an intolerable adverse event from preferred products (Byooviz, Lucentis, Eylea, Eylea HD, Vabysmo) for the relevant FDA-approved or compendial indication.
- Include clinical notes that clearly describe the inadequate response or the adverse event attributed to the preferred agent.
- Specify the preferred agent(s) tried and the indication for which they were used.
Susvimo-specific documentation required
For Susvimo requests, document the member's diagnosis (neovascular AMD, diabetic macular edema, or diabetic retinopathy) and that the member previously responded to at least two intravitreal injections of a VEGF inhibitor within the past 6 months; confirm use with the Susvimo ocular implant.
- Must document two prior intravitreal VEGF injections with demonstrated response within 6 months.
- Confirm Susvimo is used in conjunction with the Susvimo ocular implant.
Include prescribing information and AAO guidelines as supporting references
Providers are encouraged to include manufacturer prescribing information and relevant AAO Preferred Practice Pattern guidelines as supporting references when submitting documentation for prior authorization requests.
- Prescribing information listed includes Eylea, Lucentis, Beovu, Byooviz, Susvimo, Vabysmo, Cimerli, and Pavblu.
- AAO Preferred Practice Pattern guidelines for AMD, diabetic retinopathy, and retinal vein occlusions are cited as supporting sources.
Missing required documentation may lead to denial
Requests for non-preferred products may be denied if required documentation of inadequate response or intolerable adverse event to preferred products is not provided, or if chart notes documenting prior response for Susvimo are missing.
- Missing chart notes of inadequate response/intolerance to preferred agents is a documented denial risk.
- Absent documentation of prior VEGF response for Susvimo may trigger denial.
No separate authorization/denial language in reference sections
The referenced sections list citations and prescribing information but do not include specific authorization or denial wording; use the policy's criteria and documentation requirements to guide submission.
- References and prescribing information are provided; no separate authorization/denial templates are included in these chunks.
Procedure and Billing Codes
| C9161 | Injection, aflibercept hd, 1 mg (cancelled 3-31-2024) |
| C9097 | Injection, faricimab-svoa, 0.1 mg (deleted 10-1-2022) |
| C9399 | Unclassified drugs or biologicals |
| J0177 | Injection, aflibercept hd, 1 mg (effective 4-1-2024) |
| J0178 | Injection, aflibercept, 1 mg |
| J0179 | Injection, brolucizumab, 1 mg |
| J2777 | Injection, faricimab-svoa, 0.1 mg (effective 10-1-2022) |
| J2778 | Injection, ranibizumab, 0.1 mg |
| J2779 | Injection, ranibizumab, via sustained release intravitreal implant (susvimo), 0.1 mg (effective 7/1/2022) |
| J3490 | Unclassified drugs |
Key Definitions
Clinical Background and Rationale
Vascular endothelial growth factor (VEGF) inhibitors are used to treat a range of retinal and choroidal vascular conditions characterized by pathologic neovascularization or vascular permeability. Indications listed in the policy include neovascular (wet) age-related macular degeneration (AMD), diabetic macular edema (DME), macular edema following retinal vein occlusion (BRVO and CRVO), proliferative diabetic retinopathy (as adjunct to photocoagulation or vitrectomy), retinopathy of prematurity (ROP), and choroidal neovascularization from multiple causes (for example, angioid streaks, pathologic myopia, presumed ocular histoplasmosis syndrome, uveitis, choroidal rupture/trauma, and idiopathic causes). These agents — including both off‑label bevacizumab and FDA‑approved ranibizumab, aflibercept, and faricimab products — are employed to reduce neovascular growth and vascular leakage, aiming to improve or preserve best‑corrected visual acuity and limit progression of vision loss.
Policy Revisions and References
Policy 09.03.12 was created.
Policy was reviewed (no material clinical policy statement changes noted in brief).
Policy was revised in October 2025.
Current policy version became effective January 1, 2026.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.