ModifiedPremera BluecrossPolicy 5.01.620

MEDICAL POLICY 5.01.620 Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders

Defines medical necessity coverage criteria for listed intravitreal VEGF (and Ang-2/VEGF bispecific) inhibitors for ocular disorders (AMD, DME, RVO, DR, mCNV, ROP) under Premera's medical benefit, including required prior bevacizumab trial, combination-exclusion per eye, length of approval and documentation requirements.

Policy Summary

PayerPremera Bluecross

PolicyMEDICAL POLICY 5.01.620 Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders

Policy CodePolicy 5.01.620

Change TypeModified — added Pavblu, updated Susvimo, clarified combination exclusions and authorization duration

Effective DateOct 1, 2025

Next Review Date

Key ActionSubmit office visit notes documenting diagnosis, medication history, and that the individual tried bevacizumab with inadequate response or intolerance.

POLICY UPDATE CHANGES

Added Pavblu (aflibercept-ayyh) coverage criteria and HCPCS Q5147 (04/01/25).

Updated Susvimo coverage to require prior response to at least two intravitreal injections of a VEGF inhibitor and added coverage criteria for certain individuals with diabetic macular edema.

Added Macugen, Susvimo, and Vabysmo to include use is not in combination with Pavblu (2025 update).

HCPCS code J2503 (Macugen) removed 10/01/25.

Added coverage criteria for Vabysmo for macular edema following RVO (2024 Update).

Added Eylea coverage for retinopathy of prematurity (2023 Update).

10+

AMD, DME, DR, RVO, mCNV, ROPCovered indications (examples)

12 monthsMax authorization duration

Prior bevacizumab trialRequired condition

Coverage summary

Overview: This Premera coverage criteria (Policy number 5.01.620; status: MODIFIED; effective 2025-10-01; last review 2025-09-09) defines medical necessity for listed intravitreal VEGF and Ang-2/VEGF bispecific inhibitors for ocular disorders. The policy requires that the individual has tried bevacizumab (including biosimilars) and had an inadequate response or intolerance before other listed agents will be considered for coverage. Combination-use exclusions apply on a per each eye treated basis. Initial non-formulary exception reviews and authorizations may be approved for up to 12 months, with re-authorization up to 12 months if drug-specific criteria and clinical response documentation are met.

Key summary

Agents listedBeovu, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Macugen, Pavblu, Susvimo, Vabysmo (and biosimilars)

Covered indications (examples)Neovascular (wet) AMD; Diabetic Macular Edema (DME); Diabetic Retinopathy (DR); Macular edema following RVO; myopic CNV; Retinopathy of prematurity (ROP)

Max authorization durationInitial and re-authorization reviews may be approved up to 12 months

Required conditionPrior trial of bevacizumab (including listed biosimilars) with inadequate response or intolerance required before coverage of listed agents

Effective date2025-10-01

Last review date2025-09-09

Policy number5.01.620

PayerPremera (medical benefit)

Agent-specific medical necessity criteria

General drug-specific medical necessity

Each agent may be considered medically necessary when ALL of the following are met:

ALL of the following

Diagnosis is one of the agent-specific listed ocular indications (see agent nodes below)
The individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab
For bevacizumab eye-related injections no review is needed; references include biosimilars
Combination exclusion (per each eye treated): Per each eye treated, the agent is not used in combination with certain other listed VEGF/related agents
Combination exclusions vary by agent; see agent-specific children

Relevant HCPCS codes

HCPCS codes for listed agentsHCPCSCovered

J0177	Injection, aflibercept hd (Eylea HD) mg
J0178	Injection, aflibercept (Eylea), 1 mg
J0179	Injection; brolucizumab-dbll (Beovu,) mg
J2777	Injection, faricimab-svoa (Vabysmo), 0.1 mg
J2778	Injection, ranibizumab (Lucentis), 0.1 mg
J2779	Injection, ranibizumab, via intravitreal implant (Susvimo) 0.1 mg
J2503	Injection, pegaptanib sodium (Macugen), 0.3 mg
J3590	Unclassified biologics
Q5124	Injection, ranibizumab-nuna; biosimilar (Byooviz) 0.1 mg
Q5128	Injection, ranibizumab-eqrn biosimilar (Cimerli) 0.1 mg

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What providers must do

Documentation Required

Medical record documentation

Submit office visit notes documenting diagnosis, relevant history, medication history, physical evaluation, and documentation that the individual tried bevacizumab with inadequate response or intolerance.

Diagnosis (office visit notes)
Relevant medical history and physical evaluation
Medication history documenting trial of bevacizumab and evidence of inadequate response or intolerance

Prior Authorization

Prior authorization / non-formulary exception duration

Non-formulary exception reviews and all other reviews for drugs in this policy may be approved for up to 12 months. Re-authorization may be approved up to 12 months if drug-specific criteria are met and chart notes demonstrate continued positive clinical response.

Background, evidence, and definitions

Background: This policy covers intravitreal VEGF inhibitors and Ang-2/VEGF bispecific agents used to treat retinal vascular diseases (examples: neovascular AMD, DME, DR, RVO, mCNV, ROP). The purpose is to define agent-specific indications and medical necessity while managing appropriate use and safety. Combination-use exclusions (per-eye) are included to prevent simultaneous administration of multiple overlapping biologic agents in the same eye and to align coverage with available prescribing information and evidence reviews.

Evidence	Summary
AAO Preferred Practice Pattern
Considers aflibercept, bevacizumab, and ranibizumab first-line for nAMD (AAO guidance cited) — supports agent interchangeability and first-line choices.
Clinical trials (TENAYA/LUCERNE/STAIRWAY/AVENUE/YOSEMITE/RHINE/BOULEVARD)
Phase II/III trials demonstrate efficacy and durability for faricimab (supporting use in nAMD and DME; extended dosing shown in STAIRWAY and TENAYA/LUCERNE).
Cochrane / Systematic reviews and comparisons
Meta-analyses show VEGF inhibitors improve visual acuity vs no treatment; bevacizumab and ranibizumab have comparable efficacy and safety in trials and reviews.
Policy updates / history
2025 updates added Pavblu and clarified Susvimo prior-response requirement; 2023–2024 updates added ROP and RVO indications and Vabysmo; non-formulary exception approvals up to 12 months.
Coding and product references
HCPCS codes list (J0177, J0178, J0179, J2777, J2778, J2779, Q5124, Q5128, Q5147, etc.) and prescribing information citations for listed agents.

Definitions:

Per each eye treated: Combination exclusions and use restrictions are applied on an eye-by-eye basis; agents may not be used in combination within the same eye.

Bevacizumab: Includes bevacizumab and referenced biosimilars (policy lists examples such as bevacizumab-adcd, bevacizumab-awwb, bevacizumab-bvzr, bevacizumab-maly, bevacizumab-ayyh); prior use of bevacizumab with inadequate response or intolerance is required before coverage of listed agents.

Policy revision history

04/01/25added

Added Pavblu (aflibercept-ayyh) coverage criteria and HCPCS code Q5147 effective 04/01/25; updated multiple agents' combination exclusions to include Pavblu.

2025 (interim reviews through 09/01/25)revisedLatest

Updated Susvimo coverage: require prior response to at least two intravitreal injections of a VEGF inhibitor; added Susvimo coverage for certain individuals with diabetic macular edema and diabetic retinopathy (interim reviews 2025).

2025 (04/01/25 update)added

Administrative and scope notes

Administrative notes: Payer = Premera; Policy number = 5.01.620; coverage stance = mixed; this policy has a material change flag for recent updates (has_material_change = true). Operational notes: All medications listed are managed under the medical benefit and are subject to FDA dosage and administration prescribing information. Non-formulary exception and initial authorization reviews may be approved for up to 12 months.

Policy Summary

PayerPremera Bluecross

PolicyMEDICAL POLICY 5.01.620 Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders

Policy CodePolicy 5.01.620

Change TypeModified — added Pavblu, updated Susvimo, clarified combination exclusions and authorization duration

Effective DateOct 1, 2025

Next Review Date

Key ActionSubmit office visit notes documenting diagnosis, medication history, and that the individual tried bevacizumab with inadequate response or intolerance.

On This Page

Beovu (brolucizumab-dbll) - Medical Necessity

ALL of the following

Indications (any)
- Neovascular (Wet) Age-Related Macular Degeneration (AMD)
- Diabetic Macular Edema (DME)
The individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab
Combination exclusion (per eye): Per each eye treated, Beovu (brolucizumab-dbll) is not used in combination with Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-eqrn), Eylea/Eylea HD (aflibercept), Lucentis (ranibizumab), Macugen (pegaptanib), Pavblu (aflibercept-ayyh), Susvimo (ranibizumab), or Vabysmo (faricimab-svoa)

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Byooviz (ranibizumab-nuna) - Medical Necessity

ALL of the following

Indications (any)
- Neovascular (Wet) Age-Related Macular Degeneration (AMD)
- Macular Edema Following Retinal Vein Occlusion (RVO)
- Myopic Choroidal Neovascularization (mCNV)
The individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab
Combination exclusion (per eye): Per each eye treated, Byooviz (ranibizumab-nuna) is not used in combination with Beovu (brolucizumab-dbll), Eylea/Eylea HD (aflibercept), Susvimo (ranibizumab), or Vabysmo (faricimab-svoa)

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Cimerli (ranibizumab-eqrn) - Medical Necessity

ALL of the following

Indications (any)
- Neovascular (Wet) Age-Related Macular Degeneration (AMD)
- Macular Edema Following Retinal Vein Occlusion (RVO)
- Diabetic Macular Edema (DME)
- Diabetic Retinopathy (DR)
- Myopic Choroidal Neovascularization (mCNV)
The individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab

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Eylea (aflibercept) - Medical Necessity

ALL of the following

Indications (any)
- Neovascular (Wet) Age-Related Macular Degeneration (AMD)
- Diabetic Macular Edema (DME)
- Diabetic Retinopathy (DR)
- Macular Edema Following Retinal Vein Occlusion (RVO)
- Retinopathy of Prematurity (ROP)
The individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab
Combination exclusion (per eye): Per each eye treated, Eylea (aflibercept) is not used in combination with Beovu (brolucizumab-dbll), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-eqrn), Lucentis (ranibizumab), Macugen (pegaptanib), Pavblu (aflibercept-ayyh), Susvimo (ranibizumab), or Vabysmo (faricimab-svoa)

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Eylea HD (aflibercept) - Medical Necessity

ALL of the following

Indications (any)
- Neovascular (Wet) Age-Related Macular Degeneration (AMD)
- Diabetic Macular Edema (DME)
- Diabetic Retinopathy (DR)
The individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab
Combination exclusion (per eye): Per each eye treated, Eylea HD (aflibercept) is not used in combination with Beovu (brolucizumab-dbll), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-eqrn), Lucentis (ranibizumab), Macugen (pegaptanib), Pavblu (aflibercept-ayyh), Susvimo (ranibizumab), or Vabysmo (faricimab-svoa)
Includes Pavblu per brief/history

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Lucentis (ranibizumab) - Medical Necessity

ALL of the following

Indications (any)
- Neovascular (Wet) Age-Related Macular Degeneration (AMD)
- Macular Edema Following Retinal Vein Occlusion (RVO)
- Diabetic Macular Edema (DME)
- Diabetic Retinopathy (DR)
- Myopic Choroidal Neovascularization (mCNV)
The individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab
Combination exclusion (per eye): Per each eye treated, Lucentis (ranibizumab) is not used in combination with Beovu (brolucizumab-dbll), Eylea/Eylea HD (aflibercept), Macugen (pegaptanib), Pavblu (aflibercept-ayyh), Susvimo (ranibizumab), or Vabysmo (faricimab-svoa)

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Macugen (pegaptanib) - Medical Necessity

ALL of the following

Indications (any)
- Neovascular (Wet) Age-Related Macular Degeneration (AMD)
The individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab
Combination exclusion (per eye): Per each eye treated, Macugen (pegaptanib) is not used in combination with Beovu (brolucizumab-dbll), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-eqrn), Eylea/Eylea HD (aflibercept), Lucentis (ranibizumab), Pavblu (aflibercept-ayyh), Susvimo (ranibizumab), or Vabysmo (faricimab-svoa)

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Pavblu (aflibercept-ayyh) - Medical Necessity

ALL of the following

Indications (any)
- Neovascular (Wet) Age-Related Macular Degeneration (AMD)
- Diabetic Macular Edema (DME)
- Diabetic Retinopathy (DR)
- Macular Edema Following Retinal Vein Occlusion (RVO)
The individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab

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Susvimo (ranibizumab via ocular implant) - Medical Necessity

Note: Susvimo coverage updated to require prior response to at least two intravitreal injections of a VEGF inhibitor

ALL of the following

Indications (any)
- Neovascular (Wet) Age-Related Macular Degeneration (AMD)
- Diabetic Macular Edema (DME)
- Diabetic Retinopathy (DR)
The individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab

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Vabysmo (faricimab-svoa) - Medical Necessity

ALL of the following

Indications (any)
- Neovascular (Wet) Age-Related Macular Degeneration (AMD)
- Diabetic Macular Edema (DME)
- Macular Edema Following Retinal Vein Occlusion (RVO)
The individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab
Combination exclusion (per eye): Per each eye treated, Vabysmo (faricimab-svoa) is not used in combination with Beovu (brolucizumab-dbll), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-eqrn), Eylea/Eylea HD (aflibercept), Lucentis (ranibizumab), Macugen (pegaptanib), Pavblu (aflibercept-ayyh), or Susvimo (ranibizumab)

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Investigational / Not covered uses

All other uses not outlined in this policy

ALL of the following

Uses not listed in the policy are considered investigational and not covered
Medications are subject to FDA dosage and administration prescribing information

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Authorization duration and re-authorization

ALL of the following

Initial non-formulary exception reviews and all other reviews may be approved up to 12 months
Re-authorization may be approved up to 12 months if drug-specific criteria are met and chart notes demonstrate continued positive clinical response

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Initial approvals: up to 12 months
Re-authorization: may be approved up to 12 months with documentation of continued clinical benefit

Documentation Required

Agent-specific prior-response requirement for Susvimo

For Susvimo coverage for AMD, require prior response to at least two intravitreal injections of a VEGF inhibitor (per policy history).

Affected HCPCS code: J2779

Operational impact for ordering and billing: Combination exclusions are applied per each eye treated, so billing and authorization teams must verify the agent will not be coadministered in the same eye with any listed excluded agents. Avoid coadministration and cross-check planned agents against the policy's exclusion list, which includes (but is not limited to) Byooviz, Cimerli, Eylea/Eylea HD, Lucentis, Macugen, Pavblu, Susvimo, Vabysmo, and Beovu. Confirm prior bevacizumab use (including biosimilars) and document inadequate response or intolerance in the chart before approving non-formulary exceptions or prior authorization requests.

Clarified non-formulary exception authorizations may be approved up to 12 months and reinforced that medications are subject to FDA prescribing information; added language that Macugen, Susvimo, and Vabysmo are not to be used in combination with Pavblu.

10/01/25removed

HCPCS code J2503 (Macugen) removed 10/01/25 (policy history).

2024 Updateadded

Added coverage criteria for Vabysmo (faricimab-svoa) for macular edema following retinal vein occlusion (RVO).

2023 Updateadded

Added Eylea coverage for retinopathy of prematurity (ROP).