CareCost Prior authorization
Required
Check what the payer requires before you administer Eylea.
Prior authorization · clinical prerequisites · quantity limits · reauthorization
28 payer policy sets carry an aflibercept coverage policy · source-linked · reviewed August 2026
Aetna + wet AMD is shown as a live example until you choose a payer.
This payer requires an approval on file before Eylea is purchased or administered for this member.
The indications below including FDA-approved indications and
Covered under ICD-10 H35.32.
Authorization of 6 months may be granted for treatment of
What opens in CareCost
Aetna · Eylea · Wet AMD
For every requirement: the exact payer criteria, the source citation, a check-off, and a save to the patient’s chart.
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Aetna · Eylea · Wet AMD
You have already checked the policy, indication and covered dose. Open the remaining requirements and work them as a patient checklist.
CareCost tracks Eylea coverage requirements across 28 payer policy sets.
Aetna · Anthem / Elevance · Cigna · UnitedHealthcare · Regence · Premera · BCBS plans + more
Coverage clearance is only the first step.
CareCost carries the same patient through the entire workflow.
Finish this patient’s estimate →24 of 28 commercial payers with an aflibercept policy require prior authorization. Clinical prerequisite, quantity-limit and reauthorization rules vary by indication and by plan; 388 rules apply across the 28 payers CareCost has read.
24 require PA · 22 require a documented clinical prerequisite · 5 restrict site of care · 24 rules set quantity limits
24 of the 28 aflibercept policies CareCost has read require an approval on file before Eylea is purchased or administered.
Coverage depends on the indication in the payer’s aflibercept policy and the ICD-10 code billed: wet age-related macular degeneration, diabetic macular edema, macular edema following retinal vein occlusion, diabetic retinopathy or retinopathy of prematurity.
22 of 28 payers require a preferred product first, most often repackaged bevacizumab (Avastin) — though a ranibizumab product (Byooviz, Cimerli or Lucentis) is named instead at several payers, and BCBS Arkansas’s preferred list runs to Byooviz, Lucentis, Pavblu and Vabysmo.
24 rules set a per-eye dosing ceiling at the labeled interval: 2 mg per eye every 4 weeks at first, extending to every 8 weeks, with a 0.4 mg per-eye dose every 10 days for retinopathy of prematurity. Most payer policies write that ceiling directly into the coverage criteria.
4 rules set a renewal window, most commonly every 12 months, before a payer approves continued treatment.
5 payers CareCost has read restrict where the injection can be administered.
Nine products share the anti-VEGF injection class that treats wet AMD, diabetic macular edema, macular edema after retinal vein occlusion, diabetic retinopathy and retinopathy of prematurity: Eylea itself (J0178, Regeneron), Eylea HD (J0177, Regeneron, 8 mg; a separate code, not interchangeable on the claim), the aflibercept biosimilar Pavblu (Q5147, Amgen), Vabysmo (J2777, Genentech), the ranibizumab products Lucentis (J2778), Cimerli (Q5128) and Byooviz (Q5124), Beovu (J0179, Novartis), and repackaged bevacizumab, Avastin (J9035, off-label). 22 of the 28 aflibercept policies CareCost has read require a preferred product first, and for Eylea that step is most often bevacizumab.
| Payer | Indication | Prerequisite, quoted from the policy |
|---|---|---|
| BCBS Kansas Commercial |
Wet AMD | “Patient must have an intolerance or failure to Byooviz, Cimerli, OR Lucentis prior to the consideration of aflibercept” |
| BCBS Michigan Commercial |
Wet AMD | “Treatment with bevacizumab or a bevacizumab biosimilar has been ineffective, not tolerated or contraindicated” |
| BCBS Arkansas Commercial |
All aflibercept indications | “Initial request must be for a preferred product. If initial request is not a preferred product, an administrative denial will be issued.” |
| Anthem / Elevance Commercial |
Wet AMD, RVO, DME, DR | “Individual has had a trial and inadequate response or intolerance to one preferred agent” |
There is no national coverage determination for aflibercept. Coverage runs through your MAC’s LCD for intravitreal anti-VEGF drugs; the governing local coverage determinations are published in the CMS Medicare Coverage Database, and a MAC can differ from its neighbour on the same drug.
This is the Original Medicare answer. A Medicare Advantage plan administers the same Part B benefit but can layer its own prior-authorization rules on top — check the plan’s own policy rather than assuming the Original Medicare rules below carry over.
The diagnosis selector above keys on the same indication codes shown in the table: the Clearance corpus stores each payer’s rules against the indication, not the ICD-10 code by itself, so picking “Wet AMD” or “Diabetic macular edema” is what routes the scan to the right rules. Each ICD-10 code also carries its own laterality (a right-eye, left-eye or bilateral 7th character), which belongs on the claim line alongside the RT, LT or 50 modifier. Pick the payer and the indication, and the scan reads back that payer’s prior-authorization, clinical-prerequisite, quantity-limit and reauthorization rules for it.
MUE J0178 is 4 units per day (two eyes at 2 units each). Eylea is not reported with an administration code: the injection itself is the procedure, 67028, reported per eye, RT or LT on the line, or once with modifier 50 when both eyes are injected at the same visit, allowed at 150% of the fee schedule. The drug line carries the same eye modifier beside JZ, since each dose is drawn from one single-dose vial or prefilled syringe. 96372 is not a valid administration code for Eylea on any claim, Medicare or commercial.
Payer citation language above is drawn from CareCost’s own aflibercept policy corpus (28 payers). Check the specific payer’s language →
Wet age-related macular degeneration is a covered indication in all 28 of the aflibercept policies CareCost has read; diabetic macular edema, macular edema after retinal vein occlusion and diabetic retinopathy are covered in 27, and retinopathy of prematurity in 22. Coverage almost always comes with a condition attached — 22 of 28 payers require a preferred product first. Check this patient’s payer →
Most of them, yes. 22 of 28 aflibercept payers require a preferred product first, and bevacizumab (Avastin, off-label, repackaged) is the one named most often — BCBS Kansas requires “a contraindication, intolerance, or failure to a bevacizumab product prior to the consideration of another ophthalmic VEGF-inhibitor product.” It is not universal: BCBS Arkansas’s preferred list is Byooviz, Lucentis, Pavblu and Vabysmo, and “if initial request is not a preferred product, an administrative denial will be issued.” Check this patient’s payer →
24 of the 28 payers CareCost has read require prior authorization before Eylea is covered. The packet generally needs the indication, the ICD-10 code, and documentation of the clinical prerequisite for that indication — Anthem’s CC-0072 VEGF Inhibitors Step Therapy table names 14 products, and Anthem’s clinical-prerequisite rule requires “individual has had a trial and inadequate response or intolerance to one preferred agent” first. CareCost turns the applicable payer policy into a patient-level checklist. Open patient clearance →
There is no national coverage determination for aflibercept. Coverage runs through your MAC’s LCD for intravitreal anti-VEGF drugs, and a Medicare Advantage plan can layer its own prior-authorization rules on top of the Part B benefit. See Original Medicare details ↓
Wet AMD is a covered indication in all 28 of the aflibercept policies CareCost has read, but coverage usually requires a step first. BCBS Michigan requires that “treatment with bevacizumab or a bevacizumab biosimilar has been ineffective, not tolerated or contraindicated”; Kaiser Permanente requires wet AMD patients to have “failed or is intolerant to bevacizumab.” A denial usually traces back to one of those steps missing from the chart. Check this patient’s payer →
4 rules in the corpus set a reauthorization window, and most run on a 12-month cycle rather than a fixed dose count. BCBS Kansas and Capital BlueCross both write that “prior authorization validity may be renewed every 12 months (365 days) thereafter, unless otherwise specified,” and Wellmark grants a further 12 months to members who have demonstrated continued clinical response. Retinopathy of prematurity is the exception at BCBS Kansas, where renewal covers up to four additional doses rather than a calendar year.
Data current: payer policies Aug 2026 · reviewed dates come from each payer
Payer medical and specialty-drug policies · prior-authorization criteria · clinical prerequisite and quantity-limit criteria · reauthorization criteria. Medicare coverage from the CMS Medicare Coverage Database. Every CareCost requirement links back to its source policy.