Ophthalmologic VEGF Inhibitors Policy Revised — Effective Apr 1, 2026

UnitedHealthcare lists the Ophthalmologic VEGF Inhibitors policy as revised, effective April 1, 2026, in the UMR March 2026 Medical Benefit Drug Policy Updates. The bulletin is an index-style notice and does not include specific changes to clinical criteria, prior authorization, dosing limits, or product-level distinctions. Because the bulletin provides only status and effective date, providers should consult the full revised policy to determine exact coverage, utilization management, and coding implications. Treat this notice as an alert to review the authoritative policy text before making clinical-coverage decisions.

Cigna: Glaucoma Surgery—Category III Codes 0449T & 0671T Cross‑Referenced (Apr 15, 2026)

Cigna’s April 15, 2026 revision cross-references Glaucoma Surgical Procedures within its Related Coverage Resources and explicitly maps Category III CPT codes 0449T and 0671T to those glaucoma policy references. The update does not change or provide standalone clinical coverage criteria, billing instructions, or authorization requirements for glaucoma surgery; it functions as an index linking those Category III codes to other policies where they may be considered medically necessary for specific indications. Providers should consult the listed related coverage policies for detailed medical necessity rules or coding guidance for procedures using 0449T and 0671T. The revision signals that emerging glaucoma procedures coded with Category III codes are being tracked centrally across Cigna’s policy network rather than addressed in this excerpt as a separate coverage policy.

UnitedHealthcare: Tepezza (teprotumumab) coverage — 8-dose lifetime limit, prescriber and concomitant-use restrictions

UnitedHealthcare’s March 1, 2026 revision establishes formal coverage criteria for teprotumumab (Tepezza) in thyroid eye disease, limiting authorization to a lifetime maximum of 8 doses and requiring dosing per FDA labeling (initial 10 mg/kg then seven 20 mg/kg infusions every 3 weeks). Treatment must be prescribed by an endocrinologist or ophthalmologist, patients must meet defined diagnostic and severity criteria (active CAS-based disease or chronic disease meeting proptosis thresholds) and be euthyroid or on appropriate thyroid therapy. Concomitant use with other biologic immunomodulators (e.g., rituximab, tocilizumab, sarilumab) is prohibited, and prior intolerance/failure of glucocorticoids is required in many cases. The policy is grounded in randomized trial evidence showing rapid, clinically meaningful proptosis and symptom improvement and aligns with ATA/ETA guidance by operationalizing CAS and proptosis thresholds for utilization review.

Feedback Request: Policy 7.01.508 Blepharoplasty/Ptosis/Brow Ptosis (comments due Mar 5, 2026)

Premera Blue Cross is requesting stakeholder feedback by March 5, 2026 on a list of policies that includes 7.01.508: “Blepharoplasty, Blepharoptosis and Brow Ptosis Surgery.” The source material provides only the policy number and title; it contains no redlined language, coverage criteria, coding, or clinical guidance for these procedures. Because the document is an administrative notice, there is no basis to infer changes to indications, documentation, or preauthorization requirements for blepharoplasty, ptosis, or brow ptosis surgery. Providers should note the inclusion of 7.01.508 in the feedback request and submit comments by the deadline if they wish to influence any forthcoming substantive revisions.

Medicare Part B Step Therapy: Ophthalmic VEGF Class & Step Therapy Clarified

Effective 03/01/2026, Baylor Scott & White Health Plan updated Medicare Part B Step Therapy Policy (Policy 307) to add and remove multiple therapeutic classes and clarify step therapy rules. The ophthalmic VEGF inhibitor class is now defined specifically for ophthalmic indications, with Avastin designated as Preferred and agents including Beovu, Byooviz, Eylea (regular and HD), Lucentis, Pavblu, Susvimo and Vabysmo listed as Non‑Preferred for ophthalmic use. The policy clarifies that step therapy requirements apply to all preferred drugs under the policy and that coverage determinations for other Medicare outpatient drugs are handled per referenced BSWHP policies. The revision log (through 02/26/2026) documents iterative class additions (e.g., Trop‑2 agents, PD‑1 inhibitors) and removals (notably methotrexate), reflecting active maintenance of the step therapy framework.

Cigna: Lacrisert (hydroxypropyl cellulose) Covered 1-Year with Prior Tears Trial

Effective March 1, 2026, Cigna’s Individual and Family Plans (policy IP0721) clarify Lacrisert (hydroxypropyl cellulose ophthalmic insert) coverage for ocular conditions associated with moderate to severe dry eye. Approval is granted for up to 1 year when criteria are met, and a documented prior trial of artificial tears is required before authorization. The policy lists example covered conditions including decreased corneal sensitivity, exposure keratitis, keratoconjunctivitis sicca, and recurrent corneal erosions, aligning coverage with the FDA-labeled indication. The update references AAO 2024 guidance noting slow‑release hydroxypropyl cellulose inserts can be helpful for patients who cannot use artificial tears, supporting Lacrisert’s place in therapy.

Cigna: Consolidated Adalimumab Ophthalmology Criteria (effective 2026-03-15)

Cigna updated and consolidated adalimumab coverage criteria for ophthalmic and related inflammatory indications effective 2026-03-15, clarifying FDA‑approved uses (including noninfectious uveitis and extra‑ocular disorders such as Behçet’s disease and scleritis). The policy defines distinct initial and continuation approval pathways with set durations (e.g., uveitis initial approvals 6 months, continuations 1 year; Behçet’s initial 3 months, continuations 1 year) and requires specialty prescribing or consultation. Continuation requires documented clinical benefit by objective measures (e.g., visual acuity, anterior chamber cell grade, CRP/ESR) or symptomatic improvement; biosimilars do not count as prior biologic trials for step therapy. Additional supported indications (scleritis, sterile corneal ulceration, pyoderma gangrenosum, sarcoidosis) and guideline-aligned use of TNF inhibitors for vision‑threatening or corticosteroid‑dependent disease are also specified.

Premera: Specific Ophthalmology CPTs (retinal prostheses, remote OCT) Now Non‑Covered

Effective March 1, 2026, Premera Blue Cross updated its Ophthalmology (MDC 02) coverage policy to designate a set of specific CPT codes as non‑covered experimental/investigational services. Non‑covered items include retinal prosthesis implantation and related intraocular electrode array procedures (e.g., 0100T, 0472T, 0473T), device interrogation/programming and visual training encounters, and new prosthesis implantation codes effective 01/01/2026. Advanced retinal imaging and remote OCT services such as the Notal Home OTC program codes (0604T–0606T) and retinal polarization scan (0469T) are also listed as non‑covered. Other emerging diagnostics (e.g., EyeBox 0615T) are included in the non‑covered list, signaling limited coverage for these novel ophthalmic technologies.

Cigna infliximab criteria for ophthalmic indications — March 2026

Cigna updated infliximab authorization criteria for ophthalmology effective 2026-03-15, adding condition-specific eligibility, dosing, and duration rules for Behcet’s disease with ocular involvement, scleritis/sterile corneal ulceration, and uveitis (including posterior uveitides and panuveitis). Initial approvals are time-limited (Behcet’s 3 months; scleritis and uveitis 6 months) with defined age cutoffs and prior-therapy requirements or specified exceptions (prior TNF inhibitor or other biologic). Continuation approvals are 1 year for established responders who have been on therapy for the specified induction period and demonstrate objective or symptomatic improvement; prescriber or ophthalmology consultation requirements are specified. Dosing caps and induction/maintenance schedules are detailed by indication, and the policy operationalizes guideline principles into measurable authorization criteria.

Cigna: Susvimo (ranibizumab implant) deemed experimental for DME, DR, Wet AMD

Effective March 1, 2026, Cigna classifies the intravitreal implant Susvimo (ranibizumab ocular implant) as experimental, investigational, or unproven for Diabetic Macular Edema, Diabetic Retinopathy, and Neovascular (Wet) AMD due to insufficient evidence of safety and improved health outcomes. The policy retains an overview of FDA-labeled indications (including prior response to ≥2 intravitreal VEGF injections) but separates that from the payer’s noncoverage decision and will be revisited only as new published data emerge. Key safety concerns driving noncoverage include a boxed warning for endophthalmitis and higher rates of implant- and procedure-related ocular adverse events (e.g., implant dislocation, conjunctival erosion, retinal detachment) observed in trials and extension phases. Although pivotal trials showed efficacy equivalent or noninferior to monthly ranibizumab injections on primary endpoints, the aggregate safety signal and reported endophthalmitis events underpin Cigna’s current noncoverage stance.