VEGF inhibitors and complement inhibitors for macular degeneration and diabetic eye disease
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Medical necessity and prior authorization requirements for intravitreal VEGF inhibitors and complement inhibitors used to treat neovascular AMD, diabetic eye disease, retinal vein occlusion, geographic atrophy, and related ophthalmic indications for BCBSMA commercial plans.
Removed Eylea and Pavlu from Cotivity program.
Clarified no prior authorization required for any bevacizumab with an ophthalmic administration.
Updated to include Pavblu to the policy (previously added earlier).
Medical Necessity and Coverage Criteria
VEGF inhibitors — general medical necessity
Bevacizumab, Beovu, Byooviz, Cimerli, Lucentis, Susvimo, and Vabysmo may be considered MEDICALLY NECESSARY when ALL of the following are met:
Applies to the listed agents in chunk 8
Eylea HD
Eylea HD may be considered MEDICALLY NECESSARY when ALL of the following are met:
Chunk 9
Eylea
Eylea may be considered MEDICALLY NECESSARY when ALL of the following are met:
Chunk 10
Pavblu
Pavblu may be considered MEDICALLY NECESSARY when ALL of the following are met:
Chunk 11
Complement inhibitors — Geographic Atrophy
Izervay or Syfovre may be considered MEDICALLY NECESSARY when ALL of the following are met:
Chunk 13
Bevacizumab ophthalmic administrations (all brands) are covered under the medical benefit and do not require prior authorization. This applies to intravitreal uses listed in the policy (for example, neovascular AMD, diabetic macular edema, diabetic retinopathy) when those uses meet applicable medical necessity criteria. Other indications or uses not listed in the agent-specific coverage criteria may be excluded unless approved through the individual consideration (exception) process.
Use of the listed agents for indications not specified in this policy (for example, geographic atrophy or other diagnoses not shown as covered for a particular agent) does not meet the stated medical necessity criteria and therefore would not be covered as described. Providers requesting coverage for such off‑label or unlisted indications should submit an individual consideration request with supporting clinical documentation and references; these requests will be reviewed on a case‑by‑case basis.
Coding and Age Requirements
| N/A | Document lists package inserts and references but provides no explicit CPT/HCPCS/ICD-10 codes in the policy text. |
Prior Authorization, Documentation, and Provider Requirements
Prior authorization required for listed non‑bevacizumab agents
Prior authorization is required for all listed non‑bevacizumab VEGF and complement inhibitor agents covered under the medical benefit; bevacizumab ophthalmic administrations do not require prior authorization.
Step requirement: trial/failure of bevacizumab
Coverage of non‑bevacizumab intravitreal VEGF agents generally requires prior treatment failure or a contraindication to Avastin (bevacizumab) before other agents will be considered.
- Criteria for multiple agents state: “Treatment failure or contraindication to Avastin (bevacizumab)” as a required condition for medical necessity.
Documentation required for prior trial/failure
Provide documentation of prior trials and failures of formulary alternatives including the name and strength of alternatives tried, dates if available, and specifics regarding the treatment failure.
- Include drug name and strength of bevacizumab (or other alternatives) used
- Provide dates of therapy when available
- Describe specifics of treatment failure or clinical reason preventing switch to formulary alternative
Materials required for individual consideration (exceptions)
For exception (individual consideration) requests include supporting clinical documentation such as clinical notes or statements, the name and strength of alternatives tried and failed (with specifics), peer‑reviewed literature, and references from recognized drug compendia or guidelines.
- Clinical notes or supporting clinical statements
- Name and strength of formulary alternatives tried and failed and specifics of failure
- Clinical literature from reputable peer‑reviewed journals
- References from nationally recognized compendia (e.g., AHFS‑DI, Lexi‑Drug, Clinical Pharmacology, Micromedex/Drugdex)
- References from consensus documents or nationally sanctioned guidelines
Denial risk if medical necessity criteria not met
Requests for non‑bevacizumab agents that do not meet the policy’s medical necessity criteria — including the age requirement, documented trial/failure or contraindication to bevacizumab, and a covered diagnosis — risk denial.
- Medical necessity criteria explicitly require age ≥18 and treatment failure/contraindication to bevacizumab for listed agents
- Covered diagnoses vary by agent and must be documented (e.g., neovascular AMD, DME, RVO, DR, mCNV, ROP for select agents; GA criteria for complement inhibitors)
Risk of denial or delay if prior authorization is missing
Requests for listed drugs that require prior authorization submitted without a required prior authorization may be denied or delayed.
- Bevacizumab ophthalmic administrations are exempt from PA; all other listed agents carry PA requirements
Clinical Background
Intravitreal Vascular Endothelial Growth Factor (VEGF) inhibitors are used to treat a range of retinal vascular and neovascular conditions including neovascular (wet) age‑related macular degeneration (AMD), diabetic macular edema (DME), macular edema secondary to retinal vein occlusion (RVO), and diabetic retinopathy (DR); certain agents are also used for retinopathy of prematurity (ROP) or myopic choroidal neovascularization (mCNV) as indicated in the agent‑specific criteria. Clinical evidence has demonstrated comparable outcomes for repackaged bevacizumab versus ranibizumab/aflibercept in many settings, which supports the policy requirement that non‑bevacizumab agents be reserved for patients who have had a treatment failure, contraindication, or are otherwise unable to use bevacizumab per the agent‑specific medical necessity criteria.
Key Definitions
Policy Revision History
Removed Eylea and Pavblu from the Cotivity program; record noted in policy history.
Minor line editing to add generic name to Avastin (bevacizumab).
Clarified that no prior authorization is required for any bevacizumab ophthalmic administration.
Updated policy to include Pavblu as a covered agent with medical necessity criteria.
Updated to require dose and frequency for Eylea to coincide with Medical claim edits.
Removed Step therapy structure and updated policy to a Prior Authorization policy; added Izervay to policy.
Moved Eylea to step 2 and added Eylea HD, Syfovre, and Bevacizumab to the policy.
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