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.

ModifiedEmpire BluecrossPolicy CC-0072

Vascular Endothelial Growth Factor (VEGF) Inhibitors — Medical Drug Clinical Criteria

Customize your policy alerts

Sign up for Empire Bluecross Policy CC-0072 alerts

Get alerted when Policy CC-0072 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Clinical coverage and utilization management criteria for intravitreal vascular endothelial growth factor (VEGF) antagonists (e.g., bevacizumab, ranibizumab, aflibercept, brolucizumab, faricimab) for ophthalmic indications under the medical benefit.

Policy Summary

PayerEmpire Bluecross

PolicyVascular Endothelial Growth Factor (VEGF) Inhibitors — Medical Drug Clinical Criteria

Policy CodePolicy CC-0072

Change TypeStep therapy, coding, and preferred agent updates

Effective DateMar 1, 2026

Last ReviewDec 8, 2025

Next Review DateDec 8, 2025

Key ActionObtain prior authorization and document the targeted ocular diagnosis plus drug, dose per eye, and dosing interval consistent with policy limits.

SourceLink

POLICY UPDATE CHANGES

Step therapy table updates were made effective 03/01/2026 and multiple prior step therapy and coding updates were recorded through 2025.

Vabysmo (faricimab-svoa) intravitreal injection CPT/HCPCS and diagnoses were added to the policy and listed as preferred in step therapy effective 05/01/2026.

HCPCS J0179 for brolucizumab (Beovu) and related ICD-10 diagnosis ranges for exudative AMD and diabetic macular edema are listed in coding sections.

multipleVEGF inhibitors listed

quantity limitsPer-eye dosing rules

requiredStep therapy

multipleBilling codes

BeovuSpecial initiation regimens

Coverage Criteria for Intravitreal VEGF Inhibitors

Avastin and bevacizumab biosimilars - Covered Indications

Covered when any ONE of the following diagnoses is present:

Avastin-class indications: A. Diabetic macular edema (including DME with diabetic retinopathy of any severity); OR B. Proliferative or moderate to severe non‑proliferative diabetic retinopathy with or without diabetic macular edema; OR C. Established neovascular 'wet' age‑related macular degeneration; OR D. Macular edema following retinal vein occlusion (RVO); OR E. Neovascular glaucoma; OR F. Choroidal neovascularization associated with myopic degeneration; OR G. Other rare causes of choroidal neovascularization (e.g., angioid streaks, choroiditis, retinal dystrophies); OR H. Radiation retinopathy; OR I. Retinopathy of prematurity.diagnosis present

Requests for Avastin and listed bevacizumab biosimilars may not be approved when the above criteria are not met and for all other indications.

Lucentis / Byooviz / Cimerli - Covered Indications

Covered when any ONE of the following diagnoses is present:

Policy Summary

PayerEmpire Bluecross

PolicyVascular Endothelial Growth Factor (VEGF) Inhibitors — Medical Drug Clinical Criteria

Policy CodePolicy CC-0072

Change TypeStep therapy, coding, and preferred agent updates

Effective DateMar 1, 2026

Last ReviewDec 8, 2025

Next Review DateDec 8, 2025

Key ActionObtain prior authorization and document the targeted ocular diagnosis plus drug, dose per eye, and dosing interval consistent with policy limits.

SourceLink

On This Page

Ranibizumab-class indications:

A. Diabetic macular edema (including DME with diabetic retinopathy of any severity); OR B. Proliferative or moderate to severe non‑proliferative diabetic retinopathy with or without diabetic macular edema; OR C. Established neovascular 'wet' age‑related macular degeneration; OR D. Macular edema following retinal vein occlusion (RVO); OR E. Choroidal neovascularization associated with myopic degeneration; OR F. Radiation retinopathy; OR G. Retinopathy of prematurity (product‑specific).

Requests for Lucentis, Byooviz, or Cimerli may not be approved when the above criteria are not met and for all other indications.

Eylea and aflibercept biosimilars - Covered Indications

Covered when any ONE of the following diagnoses is present:

Aflibercept-class indications: A. Neovascular (wet) age‑related macular degeneration (nAMD); OR B. Diabetic retinopathy (DR); OR C. Diabetic macular edema (DME); OR D. Macular edema following retinal vein occlusion (RVO).diagnosis present

Requests for Eylea and listed aflibercept biosimilars may not be approved when the above criteria are not met and for all other indications.

Beovu (brolucizumab) - Covered Indications

Covered when any ONE of the following diagnoses is present:

Beovu indications: A. Established neovascular 'wet' age‑related macular degeneration; OR B. Diabetic macular edema (including DME with diabetic retinopathy of any severity).diagnosis present

Post‑marketing safety concerns for brolucizumab are noted in the clinical background; requests may be reviewed accordingly.

Vabysmo (faricimab) - Covered Indications (top-level)

Covered when any ONE of the following diagnoses is present:

Vabysmo indications: A. Established neovascular 'wet' age‑related macular degeneration; OR B. Diabetic macular edema (including DME with diabetic retinopathy of any severity); OR C. Macular edema following retinal vein occlusion (RVO).diagnosis present

Requests for Vabysmo may not be approved when the above criteria are not met and for all other indications.

Vabysmo additional listed indications

Also covered for any ONE of the following:

Vabysmo expanded: A. Diabetic macular edema (including DME with diabetic retinopathy of any severity); OR B. Proliferative or moderate to severe non‑proliferative diabetic retinopathy with or without DME; OR C. Neovascular AMD; OR D. Macular edema following RVO; OR E. Neovascular glaucoma; OR F. Myopic choroidal neovascularization; OR G. Other rare CNV causes (angioid streaks, choroiditis, retinal dystrophies); OR H. Radiation retinopathy; OR I. Retinopathy of prematurity.diagnosis present

Supports broader listed indications for Vabysmo in the policy.

Non-preferred agent approval (step therapy exceptions)

Non-preferred agents may be approved when ANY of the following exceptions apply:

Non-preferred exceptions: I. Individual has been on the requested agent; OR II. Trial and inadequate response or intolerance to one preferred agent; OR III. Preferred agents are not FDA‑approved and do not have an accepted off‑label use for the indication while the requested non‑preferred agent does; OR IV. Non‑preferred may be approved if Avastin is the sole preferred agent approvable for that diagnosis; OR V. Lucentis/Byooviz/Cimerli may be approved if the individual currently has a Susvimo ocular implant and requests supplemental injections; OR VI. Eylea or listed aflibercept biosimilars may be approved for retinopathy of prematurity.one exception met

Step therapy lists define preferred vs non‑preferred agents; Vabysmo added to preferred effective 05/01/2026.

Initial and maintenance dosing coverage

Covered when dosing and indication match product-specific per-eye limits and intervals

Product-specific dose and interval: Drug is used for an indicated ocular diagnosis and the requested dose per eye and dosing interval match the product‑specific limits. Examples: Eylea 2 mg per eye as often as every ≥4 weeks; Eylea HD 8 mg per eye every ~28 days (±7 days); Lucentis 0.3 mg per eye for DME every ≥4 weeks or 0.5 mg per eye for nAMD every ≥4 weeks; Avastin 1.25 mg per eye every ≥4 weeks; Beovu 6 mg per eye every ≥8 weeks with permitted initiation regimens (monthly ×3 for nAMD; every 6 weeks ×5 for DME).see product limits

Exact indication‑specific dosing and overrides are detailed in the policy quantity/threshold sections.

Step therapy / Prior Authorization

Coverage is governed by step therapy lists (preferred vs non-preferred) and market-specific precertification requirements.

Step therapy application: Member coverage follows the preferred agent list first; non‑preferred agents require step therapy justification or prior authorization per policy; precertification requirements for Avastin ocular vary by market (some markets not requiring precertification; FL requires precertification).

Preferred/non‑preferred lists with effective dates are provided in the policy (e.g., Vabysmo added to preferred 05/01/2026).

Requests for intravitreal injections of the listed VEGF antagonist agents will be considered for approval only when the individual's diagnosis matches one of the agent-specific indications explicitly listed in this policy. Each agent (for example, Avastin and its biosimilars; ranibizumab products such as Lucentis, Byooviz, Cimerli; aflibercept products including Eylea and Eylea HD; brolucizumab/Beovu; and faricimab/Vabysmo) has a defined set of covered ocular diagnoses (e.g., neovascular "wet" age-related macular degeneration, diabetic macular edema and diabetic retinopathy, macular edema following retinal vein occlusion, retinopathy of prematurity, radiation retinopathy, myopic choroidal neovascularization and other listed causes).

Requests for these intravitreal agents that are submitted for indications not enumerated under the specific product criteria in the policy are not approvable under the coverage rules and may be denied.

Coverage is limited to doses and frequencies that conform to the product-specific per-eye dose limits and minimum dosing intervals described in the policy. Examples include Eylea 2 mg: up to 2 mg per eye as frequently as every 4 weeks, Lucentis 0.3 or 0.5 mg per eye: as frequently as every 4 weeks, Avastin 1.25 mg per eye: as frequently as every 4 weeks, Beovu 6 mg per eye: each eye may be treated as frequently as every 8 weeks, and Vabysmo 6 mg per eye: as frequently as every 4 weeks (see policy quantity limits for full, indication-specific details).

Requests that propose doses exceeding the stated per-eye limits or administrations more frequent than the minimum intervals (for many agents, more frequently than every 4 weeks, except where policy specifies otherwise) fall outside the stated coverage limits and may be excluded or denied.

The policy lists markets where precertification is not required for ophthalmic bevacizumab (Avastin) and biosimilars, and notes at least one market where precertification is required. Specifically, Medicaid precertification status identifies multiple states where Precertification Not Required is listed for Avastin ocular, while Precertification Required is indicated for Florida.

When precertification is required by the member's market or plan, the provider is expected to obtain authorization per the plan rules before administration to avoid potential denial or retrospective review.

Use of any listed intravitreal VEGF antagonist is considered not approvable when the individual's diagnosis does not appear among the agent-specific approved indications. The policy requires that the documented diagnosis correspond to one of the covered indications for the requested product.

Clinical review and prior authorization decisions will rely on the documented diagnosis to determine medical necessity; absence of a listed indication for the requested agent is a primary denial trigger.

The coding lists included in this policy are provided for informational purposes only. Inclusion of a procedure, diagnosis, or device code does not by itself establish coverage or medical necessity for the service; codes alone do not constitute or imply member coverage or provider reimbursement entitlement.

CPT code 67028 is listed in the policy in the context of billing for intravitreal injections of faricimab (Vabysmo), but its inclusion is informational. The listing does not impose a requirement that CPT 67028 be submitted for medical necessity review nor does it, by itself, determine coverage; providers should follow payer billing rules and the member's contract.

Billing, HCPCS/J-codes, CPT and ICD-10

Quantity-limited products (per policy)mixed

Eylea 2 mg vial	Eylea (aflibercept) 2 mg vial - quantity limit per eye and frequency
Eylea HD 8 mg vial	Eylea HD (aflibercept) 8 mg vial - quantity limit per eye and frequency
Lucentis 0.3 mg/0.5 mg	Lucentis (ranibizumab) prefilled syringe dosing and frequency limits
Byooviz 0.5 mg vial	Byooviz (ranibizumab-nuna) 0.5 mg vial - dosing limit
Cimerli 0.3 mg/0.5 mg vial	Cimerli (ranibizumab-cqrn) dosing and indications
Avastin 100 mg/400 mg vial	Avastin (bevacizumab) dosing when used ophthalmically (1.25 mg per eye)
Beovu 6 mg vial	Beovu (brolucizumab) 6 mg vial & prefilled syringe - dosing and frequency
Vabysmo 6 mg vial	Vabysmo (faricimab-svoa) 6 mg vial & prefilled syringe - dosing and frequency

HCPCS bevacizumab codesHCPCS

C9257	Injection, bevacizumab, 0.25 mg [Avastin]
J9035	Injection, bevacizumab, 10 mg [when specified as Avastin intravitreal]
Q5126	Injection, bevacizumab-maly, biosimilar, (Alymsys), 10 mg
Q5129	Injection, bevacizumab-adcd (Vegzelma), biosimilar, 10 mg
Q5107	Injection, bevacizumab-awwb, biosimilar, (Mvasi), 10 mg
Q5118	Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg

CPT and select J/HCPCS codesmixed

67028	Intravitreal injection of a pharmacologic agent
J2778	Injection, ranibizumab; 0.1 mg [Lucentis]
Q5124	Injection, ranibizumab-nuna, biosimilar, (Byooviz), 0.1 mg
Q5128	Injection, ranibizumab-eqrn (Cimerli), biosimilar, 0.1 mg
J0178	Injection, aflibercept, 1 mg [Eylea]
C9399	Unclassified drugs or biologicals [when specified as Eydenzelt (aflibercept-boav)]
J3590	Unclassified biologics [when specified as Eydenzelt (aflibercept-boav)]

Aflibercept biosimilar HCPCS codesHCPCS

Q5147	Injection, aflibercept-ayyh (Pavblu), biosimilar, 1 mg
Q5149	Injection, aflibercept-abzv (Enzeevu), biosimilar, 1 mg
Q5150	Injection, aflibercept-mrbb (Ahzantive), biosimilar, 1 mg
Q5153	Injection, aflibercept-yszy (Opuviz), biosimilar, 1 mg
Q5155	Injection, aflibercept-jbvf (Yesafili), biosimilar, 1 mg

Beovu HCPCSHCPCS

J0179

Injection, brolucizumab-dbll, 1 mg [Beovu]

HCPCS (Beovu)HCPCS

J0179

Injection, brolucizumab-dbll, 1 mg [Beovu]

CPT and HCPCS (Vabysmo)mixed

67028	Intravitreal injection of a pharmacologic agent (CPT) [informational when billed with intravitreal faricimab HCPCS]
J2777	Injection, faricimab-svoa, 0.1 mg [Vabysmo]

ICD-10 Diagnosis CodesICD-10

H35.3210-H35.3293	Exudative age-related macular degeneration
E08.311-E08.3519	Diabetes mellitus due to underlying condition with diabetic retinopathy with macular edema (selected ranges)
E09.311-E09.3519	Drug- or chemical-induced diabetes mellitus with diabetic retinopathy with macular edema (selected ranges)
E10.311-E10.3519	Type 1 diabetes mellitus with diabetic retinopathy with macular edema (selected ranges)
E11.311-E11.3519	Type 2 diabetes mellitus with diabetic retinopathy with macular edema (selected ranges)
E13.311-E13.3519	Other specified diabetes mellitus with diabetic retinopathy with macular edema (selected ranges)
H34.8110-H34.8390	Central and branch retinal vein occlusion with macular edema (selected codes)

HCPCS and specialty codes (policy history references)HCPCS

Q5124

HCPCS referenced historically for Byooviz/Vabysmo (see document history)

Per-eye dosing frequency — Agent-specific dosing limits and maximum frequency

Eylea (aflibercept) 2 mgEach eye may be treated as frequently as every 4 weeks.

Lucentis / ranibizumab (0.3 mg / 0.5 mg)Each eye may be treated as frequently as every 4 weeks (0.3 mg for DME; 0.5 mg for nAMD and other listed indications).

Avastin (bevacizumab) and biosimilarsEach eye may be treated as frequently as every 4 weeks (1.25 mg per eye when used ophthalmically).

Vabysmo (faricimab) 6 mgEach eye may be treated as frequently as every 4 weeks.

Beovu (brolucizumab) 6 mgEach eye may be treated as frequently as every 8 weeks (see initiation override for permissible more frequent initial dosing).

Dosing interval — Most agents: as frequently as every 4 weeks; Beovu specifics

Most agents (Eylea, Lucentis, Avastin, Vabysmo)May be dosed as frequently as every 4 weeks per eye.

Beovu (brolucizumab)Maintenance dosing: may be treated as frequently as every 8 weeks per eye; initiation exceptions allowed (see Beovu initiation override).

Eylea HD (aflibercept 8 mg)Dosing interval: 8 mg per eye every 4 weeks (approximately every 28 days ±7 days).

Retinopathy of prematurity (Eylea)ROP dosing listed as 0.4 mg per eye; each eye may be treated as frequently as every 10 days.

Per-eye dose limits — Examples of per-eye mg limits for multiple agents

Eylea (aflibercept) 2 mg2 mg per eye.

Lucentis (ranibizumab)0.3 mg per eye for DME; 0.5 mg per eye for nAMD, RVO, myopic CNV, radiation retinopathy.

Avastin (bevacizumab) and biosimilars1.25 mg per eye (when used for ophthalmologic indications).

Beovu (brolucizumab) 6 mg6 mg per eye.

Vabysmo (faricimab) 6 mg6 mg per eye.

Quantity limits — Quantity limits and overrides for multiple agents updated in policy

Policy quantity limits updatedQuantity limits and overrides for multiple agents (Eylea HD, Vabysmo, Beovu, Lucentis) are detailed in the policy; updates noted in document history (see revisions).

Eylea HD (aflibercept 8 mg)Listed with specific quantity limits and dosing interval (8 mg per eye every ~28 days ±7 days); quantity limits applied per indication.

Beovu (brolucizumab)Quantity limit: 6 mg per eye with maintenance interval every 8 weeks; initiation override described for initial dosing periods.

Vabysmo (faricimab)Quantity limit: 6 mg per eye with dosing as frequently as every 4 weeks; policy lists overrides and updates for coverage and step therapy.

Prior Authorization, Step Therapy, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization/clinical review is required when a drug is being reviewed for coverage under the member's medical benefit or is otherwise subject to review (including prior authorization). Clinical review will use the listed clinical criteria for the specific intravitreal VEGF antagonist to determine medical necessity for the intended/prescribed purpose.

Prior authorization required for medical-benefit drugs when coverage is sought under the member's medical benefit or when clinical review applies.
Clinical criteria (diagnosis-specific) listed under each product will be used to determine medical necessity.

Prior Authorization

Drug- and Dose-specific Prior Authorization

Prior authorization is drug- and dose-specific for intravitreal VEGF antagonist products. Requests will be reviewed against product-specific indication criteria, dosing limits, and the applicable HCPCS/CPT coding submitted with the request.

Affected HCPCS/Q/J codes include (but are not limited to): J0178 (aflibercept 1 mg), J0179 (brolucizumab 1 mg), J2777 (faricimab 0.1 mg), J9035/Q5xxx series for bevacizumab biosimilars — submit the exact HCPCS/Q-code for the product billed.
CPT 67028 is informational when billed with intravitreal injection HCPCS; inclusion does not change PA requirements.

Denial Risk

Quantity/Frequency Exceedance Risk

Requests that exceed the per-eye quantity limits or that request dosing more frequently than the specified intervals are subject to denial unless override criteria are met and documented.

Quantity/frequency examples: Eylea (and biosimilars listed) — 2 mg per eye; as frequently as every 4 weeks for most indications; Retinopathy of prematurity dosing 0.4 mg per eye as frequently as every 10 days.
Beovu — 6 mg per eye; may be treated as frequently as every 8 weeks. Override initiation dosing allowed (ADHD): AMD — monthly for first 3 doses; DME — every 6 weeks for first 5 doses (documentation required).
Vabysmo — 6 mg per eye; may be treated as frequently as every 4 weeks.
Lucentis/Byooviz/Cimerli — 0.3 mg or 0.5 mg per eye with indication-specific frequency up to every 4 weeks.

Step Therapy

Step Therapy — Non‑Preferred Agent Risk & Lists

Step therapy requirements apply per the policy's preferred and non-preferred agent lists. Use of a non-preferred agent when step therapy requires preferred agents may lead to additional documentation requirements or denial unless one of the listed exceptions is met.

Non-preferred agents may be approved if the individual has been on the requested agent previously, or has had an inadequate response or intolerance to a preferred agent (documentation required).
Exceptions include: when preferred agents are not FDA‑approved/accepted off‑label for the indication but the non-preferred agent is; Avastin as the sole preferred agent for certain diagnoses; Susvimo implant supplemental injection scenarios; ROP diagnosis approvals for specific agents.
Step therapy lists (effective dates): 07/01/2025 Preferred = Avastin, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Pavblu; Non‑Preferred = Ahzantive, Beovu, Enzeevu, Macugen, Opuviz, Yesafili. 05/01/2026 Preferred = Avastin, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Pavblu, Vabysmo; Non‑Preferred = Ahzantive, Beovu, Enzeevu, Eydenzelt, Macugen, Opuviz, Yesafili.

Prior Authorization

Precertification Requirement for Avastin (Market-specific)

Precertification requirements vary by market for Avastin ocular products. Failure to obtain required precertification where applicable may result in denial or retrospective payment outcomes.

Precertification Not Required (Avastin ocular) in: AR, CA, DC, GA, IN, IA, KY, LA, MD, MN, NE, NJ, NV, NY, NYW, OH, SC, TN, TX, VA, WA, WV, WI.
Precertification Required (Avastin ocular) in: FL.

Documentation Required

Required Clinical Documentation

Clinical documentation must support the targeted diagnosis, laterality (which eye), dosing frequency and amount per eye, prior treatment history (including trials of preferred agents and documented intolerance or inadequate response), and any exception rationale (e.g., Susvimo implant, off‑label approvals). Include operative notes, prior medication records, and visual acuity/retinal imaging when applicable.

Document the specific covered diagnosis consistent with the product's indication criteria (e.g., nAMD, DME, RVO, ROP).
Record per‑eye dosing requested and the interval; if exceeding policy limits, include clinical justification and reference to override initiation criteria where applicable (e.g., Beovu initiation regimens).
If seeking a non‑preferred agent, provide documentation of prior preferred agent trial(s) and reason for discontinuation or inadequate response.
When billing, include the HCPCS/Q/J code(s) for the product administered and CPT 67028 when applicable (informational).

Billing Rule

Vabysmo Billing Note

Billing note for Vabysmo (faricimab-svoa): when submitting claims for intravitreal injections of Vabysmo include the appropriate HCPCS code J2777 for the drug; CPT 67028 may be reported for the intravitreal injection procedure (informational only). Inclusion of CPT/HCPCS in policy content is informational and does not alter prior authorization requirements.

HCPCS for Vabysmo: J2777 — Injection, faricimab-svoa, 0.1 mg.
When billing bevacizumab products for ocular use, use the applicable HCPCS/Q/J codes (see HCPCS group).
CPT 67028: Intravitreal injection of a pharmacologic agent — informational when billed with the drug HCPCS.

Background and Rationale

Overexpression of vascular endothelial growth factor (VEGF) is implicated in several neovascular and edematous retinal diseases addressed in this policy, including diabetic retinopathy and diabetic macular edema, neovascular ("wet") age-related macular degeneration, and retinal vein occlusion. Intravitreal VEGF antagonists (such as bevacizumab, ranibizumab, aflibercept, brolucizumab, faricimab and their biosimilars) are primary therapies for these conditions.

While effective, intravitreal VEGF inhibitors carry procedure- and drug-related risks including endophthalmitis/infection, retinal detachment, traumatic lens injury, and intraocular pressure elevation. The policy also notes post-marketing safety concerns for some agents (for example, brolucizumab/Beovu has reported associations with retinal vasculitis and vascular occlusion), which inform clinical consideration and utilization management.

Key Definitions

Intravitreal VEGF antagonist — Class definition

DefinitionA class of medications administered by intraocular injection that inhibit vascular endothelial growth factor to treat retinal neovascular and edematous conditions.

Administration routeIntravitreal (intraocular) injection.

Clinical usesUsed to treat neovascular age-related macular degeneration, diabetic macular edema/diabetic retinopathy, retinal vein occlusion, and other neovascular retinal conditions.

Biosimilar / Interchangeable — Definition and examples

BiosimilarA product highly similar to a reference biologic with no clinically meaningful differences in safety, purity, and potency; may share the same indications (extrapolation may apply).

Interchangeable productAn interchangeable product meets additional FDA criteria and is expected to produce the same clinical result as the reference product in any patient; switching between RP and IP is not expected to increase risk.

ExamplesAlymsys, Mvasi, Zirabev, Vegzelma are bevacizumab biosimilars; Byooviz is a ranibizumab biosimilar; several aflibercept biosimilars are listed (Enzeevu, Pavblu, Ahzantive, Yesafili, Opuviz, Eydenzelt).

Per-eye limit — Definition and policy examples

Per-eye limit definitionThe maximum milligram amount allowed to be billed/covered per eye and the minimum interval between treatments for that eye as specified per product.

Policy examplesEylea 2 mg per eye every ≥4 weeks; Lucentis 0.3/0.5 mg per eye every ≥4 weeks; Avastin 1.25 mg per eye every ≥4 weeks; Beovu 6 mg per eye every ≥8 weeks.

Documentation requiredRequests must state drug, dose per eye, and dosing interval aligned with the product-specific per-eye limits for coverage consideration.

Beovu initiation override — Permitted initial dosing schedules

Beovu initiation override — nAMDPermits one 6 mg dose per eye monthly for the first three (3) doses for age-related macular degeneration initiation.

Beovu initiation override — DMEPermits one 6 mg dose per eye every six weeks for the first five (5) doses for diabetic macular edema initiation.

Maintenance vs initiationAfter the permitted initiation dosing, maintenance dosing must follow the product-specific per-eye interval (Beovu maintenance: as frequently as every 8 weeks).

Exudative age-related macular degeneration, diabetic macular edema, retinal vein occlusion — ICD-10 diagnosis code ranges

Exudative age-related macular degenerationICD-10 range H35.3210‑H35.3293.

Diabetic retinopathy with macular edemaSelected ranges including E08.311‑E08.3519, E09.311‑E09.3519, E10.311‑E10.3519, E11.311‑E11.3519, E13.311‑E13.3519 (when specified as proliferative in some ranges).

Retinal vein occlusion with macular edemaSelected codes including H34.8110‑H34.8390 for central and branch RVO with macular edema.

Policy Revision History and Changes

Revision date	Change summary / operational note
03/01/2026
Step therapy table updates were made effective 03/01/2026 (document history notes multiple step therapy table updates).

2026-05-01step_therapy_updateLatest

Vabysmo (faricimab-svoa) added to the preferred agents list for commercial step therapy (preferred list updated to include Vabysmo).

2026-03-01step_therapy_update

Step therapy table updates implemented (commercial and Medicaid step therapy lists revised effective March 1, 2026).

2026-01-13coding_update

Coding update removed ICD-10-CM H35.9 from intravitreal coding (document history records a coding change on January 13, 2026).

2025-07-01step_therapy_update

Step therapy preferred/non-preferred classification updated effective July 1, 2025 (preferred agents list included Avastin, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Pavblu).

2023-10-30step_therapy_update

Medicare preferred agents list included Vabysmo as of October 30, 2023 (Medicare Medical Benefit preferred agents listing).

Summary of recent policy changes and effective dates: the document history records multiple operational updates to step therapy tables and coding through 2025 and 2026, including step therapy table updates effective 03/01/2026 and other coding revisions noted in the history.

Material changes recorded in the history include additions to coding and step therapy lists (for example, addition of Vabysmo to preferred agent lists effective 05/01/2026 as noted elsewhere) and quantity-limit updates for several products; providers should consult the document history for the full list of revisions and effective dates.