CareCost Prior authorization
Required
Check what the payer requires before you schedule Vabysmo.
Prior authorization · clinical prerequisites · quantity limits · reauthorization
27 payer policy sets carry a faricimab coverage policy · source-linked · reviewed September 2026
Aetna + Wet AMD is shown as a live example until you choose a payer.
This payer requires an approval on file before Vabysmo is purchased or administered for this member.
faricimab-svoa (Vabysmo), ranibizumab (Lucentis), ranibizumab (Susvimo), ranibizumab-eqrn (Cimerli), and ranibizumab-nuna (Byooviz) is required of all Aetna participating providers
Covered under ICD-10 H35.32.
medically necessary for treatment of neovascular (wet) age-related macular degeneration
What opens in CareCost
Aetna · Vabysmo · Wet AMD
For every requirement: the exact payer criteria, the source citation, a check-off, and a save to the patient’s chart.
In CareCost: check off each requirement · save to the patient · print for the chart
Aetna · Vabysmo · 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 Vabysmo coverage requirements across 27 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 →18 of 27 commercial payers with a faricimab policy require prior authorization. Clinical prerequisite, quantity-limit and reauthorization rules vary by indication and by plan; 201 rules apply across the 27 payers CareCost has read.
Vabysmo covers three indications in this corpus: wet age-related macular degeneration (ICD-10 H35.3210, 25 of 27 payers), diabetic macular edema (ICD-10 E11.311, 26 of 27), and macular edema following retinal vein occlusion (ICD-10 H34.8110, 25 of 27). Laterality lives in the seventh character of each ICD-10 code as well as on the claim line itself — RT, LT, or modifier 50 when both eyes are treated.
18 require PA · 20 require a documented clinical prerequisite · 4 restrict site of care · 6 rules set quantity limits
18 of the 27 faricimab policies CareCost has read require an approval on file before Vabysmo is purchased or administered.
Coverage depends on the indication in the payer’s faricimab policy and the ICD-10 code billed — wet age-related macular degeneration, diabetic macular edema, or macular edema following retinal vein occlusion.
16 of 27 payers require another product or step first, almost always a documented trial of repackaged bevacizumab (Avastin). BCBS Michigan waives that trial for diabetic macular edema when visual acuity in the affected eye is 20/50 or worse.
6 rules set a dosing ceiling. BCBS Minnesota’s policy reads “Administer 6 mg intravitreally per affected eye once every 4 weeks”, and UHC caps an authorization at 12 months. Among the corpus’s 26 dosing rules, Florida Blue’s specifies that “dosage does not exceed 6 mg to each eye every 4 weeks (28 days).”
5 rules ask for a renewal rather than open-ended coverage. BCBS Michigan requires that “clinical documentation must be provided to confirm that current criteria are met and that the medication is providing clinical benefit”; HMSA initially approves 3 months of therapy; BCBS Tennessee, CareFirst and Wellmark each grant 12 months of continued treatment once the member has shown a documented response.
4 payers CareCost has read restrict where the injection can be administered. BCBS Massachusetts’ policy states Vabysmo is “Covered under Medical Benefit Only.”
Nine anti-VEGF products treat wet AMD, diabetic macular edema and macular edema after retinal vein occlusion. 16 of the 27 faricimab policies CareCost has read require a step before Vabysmo is covered, and for Vabysmo that step is almost always a documented trial of repackaged bevacizumab (Avastin, off-label) rather than a rival branded anti-VEGF product.
| Payer | Rule type | Prerequisite, quoted from the policy |
|---|---|---|
| BCBS Massachusetts Commercial |
Clinical prerequisite | “Treatment failure or contraindication to Avastin ® (bevacizumab)” |
| Premera Blue Cross Commercial |
Clinical prerequisite | “The individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab” |
| CareFirst BCBS Commercial |
Step therapy (external) | “Member has a documented inadequate response, contraindication, or intolerable adverse event to Avastin.” |
| Centene / Ambetter Commercial |
Clinical prerequisite | “Failure of bevacizumab intravitreal solution …” |
| BCBS Nebraska Commercial |
Clinical prerequisite | “Treatment with bevacizumab has been ineffective, not tolerated or contraindicated.” |
Excellus lists Vabysmo as a preferred product but still requires prior bevacizumab use: its policy specifies that “preferred status still requires prior use of a bevacizumab-containing product unless otherwise specified,” and it defines failure as “at least 3 injections that results in a suboptimal clinical response” of a bevacizumab-containing product.
There is no national coverage determination for anti-VEGF intravitreal injections. Coverage runs through your MAC’s LCD for intravitreal anti-VEGF therapy — 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. 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 J2777 is 120 units per day, covering both eyes at 60 units each. The injection itself is reported as 67028 per eye — RT or LT on the line, or once with modifier 50 when both eyes are treated at the same visit, which Medicare allows at 150% of the fee schedule ($114.23 to $171.35). The drug line carries the same eye modifier beside JZ, and a bilateral visit is two J2777 lines, one dose each. 96372 is not a valid administration code for Vabysmo on any claim, Medicare or commercial.
Payer citation language above is drawn from CareCost’s own faricimab policy corpus (27 payers). Check the specific payer’s language →
Wet AMD is a covered indication under 25 of the 27 faricimab policies CareCost has read, diabetic macular edema under 26 of 27, and macular edema after retinal vein occlusion under 25 of 27, but coverage usually depends on a prerequisite. BCBS Massachusetts requires “treatment failure or contraindication to Avastin ® (bevacizumab)”; Premera requires that “the individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab.” 16 of 27 payers require another product or step first. Check this patient’s payer →
16 of the 27 faricimab policies CareCost has read set a documented bevacizumab trial as the first step. CareFirst requires “Member has a documented inadequate response, contraindication, or intolerable adverse event to Avastin”; BCBS Nebraska requires that “treatment with bevacizumab has been ineffective, not tolerated or contraindicated.” Excellus defines that failure as “at least 3 injections that results in a suboptimal clinical response” of a bevacizumab-containing product. Check this patient’s payer →
Preferred status varies by payer. Arkansas BCBS lists Vabysmo among its preferred VEGF-inhibitor products, while Independence Blue Cross classifies faricimab (Vabysmo) as a Level 3 nonpreferred product that requires documented contraindication, intolerance or inadequate response to a preferred product first. Regence requires, in order, “1. Treatment with a Level 1 product AND 2. Treatment with a Level 2 product AND 3. Treatment with a Level 3 product” before it covers a Level 3 drug such as Vabysmo. Check this patient’s payer →
18 of the 27 payers CareCost has read require an approval on file before Vabysmo is covered. The packet generally needs the indication, the ICD-10 code, and documentation of the clinical prerequisite for that indication — Premera’s language is “the individual has tried bevacizumab and had an inadequate response or intolerance to bevacizumab.” CareCost turns the applicable payer policy into a patient-level checklist. Open patient clearance →
There is no national coverage determination for anti-VEGF intravitreal injections. Coverage runs through your MAC’s LCD for intravitreal anti-VEGF therapy, and a Medicare Advantage plan can layer its own prior-authorization rules on top of the Part B benefit. See Original Medicare details ↓
5 rules in the corpus cover reauthorization. BCBS Michigan requires that “clinical documentation must be provided to confirm that current criteria are met and that the medication is providing clinical benefit”; HMSA initially approves 3 months of therapy before reviewing response; BCBS Tennessee, CareFirst and Wellmark each grant a 12-month reauthorization once the member has demonstrated a documented clinical response. No payer in the corpus sets a shorter reauthorization interval than HMSA’s initial 3-month approval.
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.