CurrentCignaPolicy N/A

Intravitreal anti‑VEGF medication prior authorization (Eylea/Pavblu and others)

This form governs prior authorization requests for intravitreal vascular endothelial growth factor (anti-VEGF) medications (examples: Eylea, Pavblu) for Cigna members and documents clinical and administrative information required for review.

Policy Summary

PayerCigna

PolicyIntravitreal anti‑VEGF medication prior authorization (Eylea/Pavblu and others)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionFax the completed prior authorization form to (855) 840-1678 or call (800) 882-4462 for urgent requests.

SourceLink

5 business daysstandard response time

(800) 882-4462urgent phone

(855) 840-1678fax to submit

Accredopreferred specialty pharmacy

Coverage criteria for intravitreal anti-VEGF prior authorization

Clinical and administrative criteria collected

Authorization assessment will consider the following documented clinical criteria and responses on the form:

Administration and supervision: Medication is administered by or under supervision of an ophthalmologistbinary

form asks yes/no

Indication: Diagnosis is one of: Diabetic Macular Edema (DME), Diabetic Retinopathy (DR), Macular edema following retinal vein occlusion, Neovascular (wet) Age-Related Macular Degeneration, Retinopathy of Prematurity, Other neovascular ocular disease, or Otherselection

form provides checkboxes for indications

DME-specific:

Policy Summary

PayerCigna

PolicyIntravitreal anti‑VEGF medication prior authorization (Eylea/Pavblu and others)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionFax the completed prior authorization form to (855) 840-1678 or call (800) 882-4462 for urgent requests.

SourceLink

On This Page

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If DME: baseline ETDRS best-corrected visual acuity (BCVA) 20/50 or worse (less than 69 ETDRS letters) AND significant retinal thickening

both DME BCVA and retinal thickening questions are on form

DR-specific: If DR without DME: prescriber indicates diabetic retinopathy without diabetic macular edemabinary

form includes specific checkbox for DR without DME

Current therapy status: Is the patient currently receiving the requested medication (yes/no)binary

form asks current treatment status

Combination therapy disclosure: Will the requested medication be used in combination with another intravitreal VEGF inhibitor? (yes/no)binary

form queries concurrent intravitreal VEGF inhibitor use; list of intravitreal VEGF inhibitors is provided on the form

Prior bevacizumab consideration: Form documents whether the patient previously tried repackaged bevacizumab and, if yes, whether inadequate efficacy or intolerability was demonstrated; prescriber may document safety or supplier concerns about repackaged bevacizumabinformational

used for step-therapy consideration

The prior authorization form explicitly asks whether the requested intravitreal anti‑VEGF agent will be used in combination with another intravitreal vascular endothelial growth factor inhibitor. This concurrent‑use question must be answered on the form and disclosed to Cigna as part of the clinical information submitted. Use of combination intravitreal VEGF inhibitors may be considered during review and can influence coverage decisions; disclose any concurrent therapy when completing the request.

The form documents whether the patient has previously tried repackaged bevacizumab and whether that trial demonstrated inadequate efficacy or intolerability. The prescriber may also note if the safety of repackaged bevacizumab or the supplier is a significant concern. These items are collected to support step‑therapy considerations and should be completed when relevant, as absence of documented prior bevacizumab trial information may affect authorization of non‑preferred agents.

Requested medication and measurement thresholds

Requested medications listed on formmixed

	Eylea 2 mg/0.05 ml syringe
	Eylea 2 mg/0.05 ml vial
	Eylea HD 8 mg/0.07 ml
	Pavblu 2 mg/0.05 ml syringe
	Pavblu 2 mg/0.05 ml vial
	Other (specified by prescriber)

DME Visual Acuity Threshold (ETDRS)

ETDRS BCVA threshold for DME20/50 or worse (less than 69 ETDRS letters)

Retinal thickening requirement (DME)Significant retinal thickening must be present (form asks prescriber to confirm)

Assessment sourcePrescriber-reported baseline ETDRS BCVA on the prior authorization form

What providers must submit and how to request authorization

Prior Authorization

Prior Authorization Submission Required

Prior authorization is required for intravitreal anti-VEGF agents. Fax the completed prior authorization form to (855) 840-1678. If the request is urgent, call (800) 882-4462 (800.88.CIGNA). You may also submit online at www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR. Standard response time is 5 business days; call for urgent requests to expedite.

Fax: (855) 840-1678
Urgent phone: (800) 882-4462 (800.88.CIGNA)
Online: www.covermymeds.com/main/prior-authorization-forms/cigna/
Submit via SureScripts in EHR
Standard response time: 5 business days

Prior Authorization

Combination Therapy Flag

The form asks whether the requested intravitreal VEGF inhibitor will be used in combination with another intravitreal VEGF inhibitor. Concurrent use may have coverage implications; mark Yes or No on the form and provide rationale if applicable.

Question on form: "Will the requested medication be used in combination with another intravitreal vascular endothelial growth factor inhibitor?"
List of intravitreal VEGF inhibitors called out on form: repackaged bevacizumab (compounded from Avastin), Beovu (brolucizumab), ranibizumab (Lucentis, biosimilars), Susvimo (ranibizumab implant), Vabysmo (faricimab)

Documentation Required

Required Documentation on the Form

Complete all required documentation fields on the prior authorization form. Incomplete asterisked (*) items will prevent fax response. Include prescriber and practice identifiers, patient demographics, medication and administration details, diagnosis, and facility/dispensing information.

Prescriber name, specialty, and office contact
DEA, NPI or TIN (required)
Office phone and fax; office address
Patient name, Cigna ID, date of birth, address, and phone (required asterisked items)
Medication requested (product, dose, frequency, duration) and ICD-10 code
Diagnosis selection (e.g., DME, DR, RVO, wet AMD, ROP, other neovascular diseases)
Facility/doctor dispensing and administering medication: facility name, tax ID, address, state
Chronic/long-term therapy indicator (Yes/No)
Clinical information and attestation including prescriber signature and date

Documentation Required

Bevacizumab Trial Consideration

Document prior use and safety considerations for bevacizumab. The form asks whether the patient has previously tried repackaged bevacizumab and, if yes, whether inadequate efficacy or intolerability was demonstrated. It also asks the prescriber's professional opinion on safety of repackaged bevacizumab and whether the supplier is a significant concern—provide responses and supporting details as applicable.

Has the patient previously tried repackaged bevacizumab? Yes/No
If yes: Was there inadequate efficacy or intolerability? Yes/No
In prescriber's opinion, is the safety of using repackaged bevacizumab a significant concern? Yes/No
In prescriber's opinion, is the supplier of the repackaged bevacizumab a significant concern? Yes/No
Provide additional clinical information and rationale if selecting concerns or prior trial failures

Definitions and examples

Intravitreal VEGF Inhibitors Listed on Form

Included intravitreal VEGF inhibitorsBevacizumab intravitreal injection (compounded from Avastin or biosimilars; off‑label)

Included intravitreal VEGF inhibitorsBeovu (brolucizumab‑dbll intravitreal injection)

Included intravitreal VEGF inhibitorsRanibizumab intravitreal injection (Lucentis and biosimilars) and Susvimo (ranibizumab ocular implant)

Included intravitreal VEGF inhibitorsVabysmo (faricimab‑svoa intravitreal injection)

Examples — Other Neovascular Ocular Diseases

Angioid streaksExample of other neovascular disease of the eye listed on the form

Iris neovascularizationExample of other neovascular disease of the eye listed on the form

Neovascular glaucomaExample of other neovascular disease of the eye listed on the form

Pachychoroid neovasculopathy / polypoidal choroidal vasculopathyExamples of other neovascular diseases of the eye listed on the form

Presumed ocular histoplasmosis syndromeExample of other neovascular disease of the eye listed on the form

Background on intravitreal anti-VEGF use

Intravitreal anti‑VEGF agents are indicated for a range of retinal and neovascular ocular conditions and the form captures the treated diagnosis. Examples listed on the form include diabetic macular edema (DME), diabetic retinopathy (DR), macular edema following retinal vein occlusion (RVO), and other neovascular diseases of the eye. The form also elicits DME‑specific clinical data such as baseline ETDRS best‑corrected visual acuity and presence of significant retinal thickening, and asks whether therapy will be administered by or under the supervision of an ophthalmologist.