VEGF inhibitors and complement inhibitors for macular degeneration and diabetic eye disease
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Clinical coverage and prior authorization requirements for VEGF inhibitors and complement inhibitors used to treat macular degeneration, diabetic eye disease, and related retinal conditions for BCBSMA commercial members.
Updated Eylea HD with expanded FDA indications.
Removed Eylea and Pavlu from Cotivity program.
Clarified no prior authorization required for any bevacizumab with ophthalmic administration.
Coverage Criteria
MEDICALLY NECESSARY criteria for VEGF inhibitors
Covered when ALL of the following are met:
General requirements for listed VEGF inhibitors (Bevacizumab-excepted agents)
- Permitted diagnoses for this group: a. Neovascular (Wet) Age-Related Macular Degeneration (AMD); b. Macular Edema Following Retinal Vein Occlusion (RVO); c. Diabetic Macular Edema (DME); d. Diabetic Retinopathy (DR); e. Myopic Choroidal Neovascularization (mCNV).
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MEDICALLY NECESSARY criteria for complement inhibitors (GA)
Covered when ALL of the following are met:
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Complement inhibitors for Geographic Atrophy are covered only when specific anatomic and etiologic conditions are met. Specifically, coverage of Izervay (avacincaptad pegol) or Syfovre (pegcetacoplan) requires a confirmed diagnosis of Geographic Atrophy (GA) in a patient aged 18 years or older, and there must be an absence of choroidal neovascularization (CNV) in both eyes. Additionally, the GA must be secondary to age-related macular degeneration (AMD). Presence of CNV or GA from a non‑AMD cause therefore excludes coverage under these criteria.
This section does not present an explicit list of agents designated as not medically necessary. The policy summary and tables list covered agents and their formulary or prior‑authorization status, but no discrete 'not medically necessary' statements for specific intravitreal agents appear in the cited portions of the document.
Coding and Billing Codes
| Bevacizumab (all brands) | Covered under Medical Benefit Only; No Prior Authorization required |
| Beovu (brolucizumab) | Covered under Medical Benefit Only; Prior Authorization required |
| Byooviz (ranibizumab nuna) | Covered under Medical Benefit Only; Prior Authorization required |
| Cimerli (ranibizumab eqrn) | Covered under Medical Benefit Only; Prior Authorization required |
| Eylea (aflibercept) | Covered under Medical Benefit Only; Prior Authorization required |
| Eylea HD | Covered under Medical Benefit Only; Prior Authorization required |
| Lucentis (ranibizumab) | Covered under Medical Benefit Only; Prior Authorization required |
| Pavblu (aflibercept) | Covered under Medical Benefit Only; Prior Authorization required |
| Susvimo (ranibizumab) | Covered under Medical Benefit Only; Prior Authorization required |
| Vabysmo (faricimab) | Covered under Medical Benefit Only; Prior Authorization required |
| Izervay (avacincaptad pegol) | Covered under Medical Benefit Only; Prior Authorization required |
| Syfovre (pegcetacoplan) | Covered under Medical Benefit Only; Prior Authorization required |
Provider Actions — Prior Authorization & Documentation
Prior Authorization Required
Requests for intravitreal VEGF inhibitors covered under the medical benefit require prior authorization. Failure to obtain prior authorization when required may result in claim denial.
- Affected agents include Beovu, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Pavblu, Susvimo, Vabysmo (all listed as Medical Benefit with PA).
- Bevacizumab (all brands) is covered under the Medical Benefit and does NOT require prior authorization.
Use Massachusetts Medication Prior Authorization Form
Use the Massachusetts Standard Form for Medication Prior Authorization Requests to submit PA requests. You may complete the eForm online or print and fax Form #434; failure to submit a completed form (eForm or Form #434) may risk denial of the request.
- eForm link: https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadamassets/023%20E%20Form%20medication%20prior%20auth%20instruction%20prn.pdf
- Or print and fax: Massachusetts Standard Form #434
Step Therapy Status
This policy is focused on prior authorization requirements rather than a step therapy pathway. Historical step therapy edits were removed and the policy was updated to a prior authorization policy; check policy history for prior step therapy changes.
- Policy history: step therapy elements removed and policy converted to PA-focused (see history entries through 2024–2026).
- For current coverage and PA criteria, follow the Prior Authorization Required guidance above.
Step Therapy (Not Specified)
No explicit step therapy sequencing is required under this policy at present. Providers should document trials of formulary alternatives only when relevant to support medical necessity or exceptions.
- Although prior versions included step therapy, current requirements do not mandate a specific step sequence.
- If a provider asserts that formulary alternatives were tried and failed, include name, strength, dates (if available), and specifics of treatment failure in documentation.
Background
Vascular endothelial growth factor (VEGF) inhibitors and complement inhibitors are therapeutic classes used to manage a range of retinal diseases. Anti‑VEGF agents—including ranibizumab, bevacizumab, aflibercept, brolucizumab and related biosimilars—are used to treat neovascular (wet) age‑related macular degeneration (AMD), diabetic macular edema (DME), diabetic retinopathy (DR), macular edema following retinal vein occlusion (RVO), and myopic choroidal neovascularization (mCNV), among other retinal conditions. Complement inhibitors such as Izervay and Syfovre are indicated for Geographic Atrophy (GA) secondary to AMD and per policy require the absence of choroidal neovascularization in both eyes to meet coverage criteria. Studies cited in the policy also note that repackaged bevacizumab (Avastin) has not been associated with a higher risk of endophthalmitis compared with ranibizumab in large observational and randomized studies, supporting its use as a treatment option.
Definitions & Safety Notes
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