CurrentCareSourcePolicy N/A

Aflibercept (Eylea, Eylea HD) — Prior Authorization and Coverage

Defines medical benefit coverage, prior authorization requirements, and clinical criteria for aflibercept (Eylea and Eylea HD) for ophthalmic indications including adult retinal diseases and retinopathy of prematurity in neonates for CareSource members.

Policy Summary

PayerCareSource

PolicyAflibercept (Eylea, Eylea HD) — Prior Authorization and Coverage

Policy CodePolicy N/A

Change TypeAdded ROP indicationadded Eylea HD and dosing updates

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis, ophthalmologist involvement, BCVA, and prior bevacizumab trial when required.

SourceLink

POLICY UPDATE CHANGES

Added new indication for ROP.

Added Eylea HD to policy name and incorporated Eylea HD into policy.

Annual review with no updates noted on 11/08/2024.

4Adult indications

1ROP indication

6 moAdult initial approval

3 moROP initial approval

PA required

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.

Coverage Criteria for Aflibercept (Eylea, Eylea HD)

Retinal Disease (adults) - Initial Authorization

Covered when ALL of the following are met

Adult initial criteria: 1) Member is at least 18 years of age; AND 2) Medication is prescribed by or in consultation with an ophthalmologist; AND 3) Confirmed diagnosis of one of: a) Neovascular (Wet) Age-Related Macular Degeneration (AMD); b) Macular Edema following Retinal Vein Occlusion (RVO) - Eylea only; c) Diabetic Macular Edema (DME); d) Diabetic Retinopathy (DR); AND 4) Member has tried and failed bevacizumab intravitreal injection (Exception: not required for DME when visual acuity is worse than 20/50); AND 5) Documentation of best-corrected visual acuity (BCVA); AND 6) No active infection or inflammation in or around the eye(s) to be treated.

Eylea dosing (adults)

Eylea dosing by indication: AMD: 2 mg every 4 weeks for 3 months, then 2 mg every 8 weeks; RVO: 2 mg every 4 weeks; DME or DR: 2 mg every 4 weeks for the first 5 injections, then 2 mg every 8 weeks.

Eylea supplied as 2 mg/0.05 mL single-dose vial or pre-filled syringe.

Eylea HD dosing (adults)

Eylea HD dosing by indication: AMD or DME: 8 mg every 4 weeks for 3 months, then 8 mg every 8 to 16 weeks; DR: 8 mg every 4 weeks for 3 months, then 8 mg every 8 to 12 weeks.

If all requirements met, medication approved for 6 months.

Retinal Disease (adults) - Reauthorization

Covered for reauthorization when ALL of the following are met

Adult reauthorization criteria: Chart notes must include documentation of improved or stabilized visual acuity.

If all requirements are met, medication approved for an additional 12 months.

Retinopathy of Prematurity (ROP) - Initial Authorization

Covered when ALL of the following are met

ROP initial criteria: 1) Member's gestational age at birth was 32 weeks or fewer OR birth weight 1500 g or less; AND 2) Medication is prescribed by or in consultation with an ophthalmologist; AND 3) Confirmed diagnosis of Type 1 ROP defined by any of: a) Zone I ROP any stage with plus disease; OR b) Zone I or posterior Zone II ROP stage 3 without plus; OR c) Zone II ROP stage 2 or 3 with plus disease; AND 4) Member does NOT have advanced ROP (stage 4 or 5) and does not have ROP involving only Zone III; AND 5) Dosage limit: 0.4 mg (may be given bilaterally same day; may repeat after at least 10 days).

If all requirements are met, medication approved for 3 months.

Retinopathy of Prematurity (ROP) - Reauthorization

Covered for reauthorization when ALL of the following are met

ROP reauthorization criteria: 1) Member continues to have active ROP; AND 2) Member has not experienced retinal detachment, macular dragging, macular fold, or retrolental opacity.

If all requirements are met, medication approved for an additional 3 months.

Use of Eylea or Eylea HD for any condition not listed in this policy is outside the scope of coverage under this document. For requests related to indications not specified here, refer to the plan Off-Label policy for review and determination.

CareSource considers Eylea and Eylea HD to be not medically necessary for the treatment of conditions that are not listed in this policy. Requests for aflibercept for unlisted indications may be denied per the plan’s coverage rules.

Provider Requirements and Actionable Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required for Eylea and Eylea HD (aflibercept) when provided as a medical benefit. Initial authorization requires the member to meet age and prescriber requirements and have documentation as noted below. Approval duration varies by indication (see reauthorization rules).

Eylea and Eylea HD (aflibercept) classified as Medical benefit
Initial prior authorization required
Approval duration: up to 12 months for retinal disease indications; up to 3 months for ROP

Step Therapy

Bevacizumab Trial Requirement

Member must have a documented trial and failure of intravitreal bevacizumab prior to approval of aflibercept, except where specific exceptions apply (see exception list). Failure to document the bevacizumab trial and lack of clinical response may result in denial.

Bevacizumab trial required for initial authorization of retinal disease indications

Benefit Designation and Coding

Benefit designationmixed

medical benefit

Eylea and Eylea HD billed as medical benefit (no explicit CPT/HCPCS codes listed in document)

Key Definitions

Retinopathy of prematurity (ROP) — definition, staging, zones, plus disease references

DefinitionNeovascular disorder of developing retinal blood vessels in preterm infants (Retinopathy of prematurity, ROP).

Type 1 ROP diagnostic criteriaCovered when one or more of the following are present: a) Zone I ROP any stage with plus disease; b) Zone I or posterior Zone II ROP stage 3 without plus disease; c) Zone II ROP stage 2 or 3 with plus disease.

Exclusions within ROP criteriaNot covered for advanced ROP with partial or complete retinal detachment (stage 4 or 5) or ROP involving only Zone III.

Gestational/birth weight thresholdMember's gestational age at birth ≤ 32 weeks OR birth weight ≤ 1500 g required for initial authorization.

Dosage limit and administrationDosage allowed: 0.4 mg; may be given bilaterally on the same day; may be repeated after an interval of at least 10 days.

Background

Aflibercept (marketed as Eylea, and in a higher-dose formulation as Eylea HD) is an intravitreally administered vascular endothelial growth factor (VEGF) inhibitor used to treat retinal vascular and neovascular eye diseases. This policy addresses its use for specified adult retinal conditions and for retinopathy of prematurity in neonates, with dosing, prior authorization, and documentation requirements defined by indication.

Revision History

2024-11-08annual_review

Annual review of the policy conducted; no clinical updates to policy content were recorded.

2023-10-02annual_review

Annual review noting Retinopathy of Prematurity (ROP) included in the policy.

2023-04-04material_update

Eylea HD added to the policy name and incorporated into dosing and coverage provisions.

Policy Summary

PayerCareSource

PolicyAflibercept (Eylea, Eylea HD) — Prior Authorization and Coverage

Policy CodePolicy N/A

Change TypeAdded ROP indicationadded Eylea HD and dosing updates

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis, ophthalmologist involvement, BCVA, and prior bevacizumab trial when required.

SourceLink

On This Page

Exception: bevacizumab not required for DME when visual acuity is worse than 20/50

Documentation Required

Required Clinical Documentation

Providers must submit clinical documentation to support medical necessity. Include baseline and follow-up exam findings, treatment history, and objective measures of vision and response.

Chart notes documenting diagnosis and ophthalmologist involvement
Best-corrected visual acuity (BCVA) at baseline and follow-up
Documentation of prior intravitreal bevacizumab trial and clinical response (if applicable)
Treatment logs (dates of injections, dosage/strength), gestational age and birth weight for ROP
For reauthorization: notes documenting improved or stabilized visual acuity (retinal disease) or ongoing active ROP without complications

Denial Risk

Off-Label / Unlisted Indications

Requests for aflibercept for indications not listed in this policy will be considered not medically necessary and may be denied. Refer to the Off-Label policy for requests outside the stated indications.

Off-label/unlisted indications = Not medically necessary unless supported by separate policy exception

Denial Risk

Bevacizumab Step Requirement — Denial Risk

Failure to document a prior trial and failure of intravitreal bevacizumab where required may trigger denial of the request. Ensure explicit documentation of the bevacizumab regimen and outcome before submission.

Denial risk if prior bevacizumab trial is not documented for eligible indications
Include dates, doses, and clinical response to bevacizumab in chart notes

Neovascular (Wet) Age-Related Macular Degeneration (AMD) — definition and relation to aflibercept

DefinitionForm of age-related macular degeneration characterized by growth of new blood vessels under the macula (neovascular or 'wet' AMD) leading to potential rapid central vision loss.

Relation to aflibercept (Eylea/Eylea HD)Aflibercept (Eylea) is FDA-approved and indicated for treatment of neovascular (wet) AMD; Eylea HD is a high-dose, extended-interval formulation (fewer indications).

Clinical contextNeovascular AMD is the less common but more rapidly progressive form of AMD and is treated with intravitreal anti-VEGF agents including aflibercept.

2021-10-22additionLatest

New policy created and ROP indication was added to the coverage document.