Medicare AdvantagePrior AuthHigh impact
Aflibercept Products (Eylea®, Eylea® HD, Pavblu™) (Revised)
Humana·FL, KY, SC · Ophthalmology·Medicaid
Effective date
Jan 1, 2025
We identified it
Jun 24, 2026
Summary
Humana has revised its prior authorization policy for aflibercept products (Eylea, Eylea HD, and Pavblu) used to treat various retinal conditions. The policy requires prior authorization for these expensive eye injection medications and mandates step therapy with bevacizumab first, unless contraindicated or the patient has specific vision thresholds.
Action Required
Immediately: Billing and clinical staff must ensure prior authorization is obtained for all Eylea, Eylea HD, and Pavblu injections for Humana Medicare and Medicaid patients. Providers must document contraindication/intolerance to bevacizumab OR prior bevacizumab failure OR vision of 20/50 or worse (for DME/DR cases) to bypass step therapy requirements. Update EMR templates to capture required clinical criteria. Claims will be denied without proper prior authorization.