Aflibercept Products (Eylea®, Eylea® HD, Pavblu™) (Revised)

By March 1, 2026: Billing and prior authorization teams must update internal workflows and system documentation to reflect the revised policy. Key actions: (1) Confirm system logic for DME and DR requests—when vision is 20/50 or worse, bypass bevacizumab step-therapy requirement and approve aflibercept directly; (2) For AMD and RVO, maintain existing step-therapy logic requiring bevacizumab trial first or documented contraindication/intolerance; (3) For ROP indications, remove any step-therapy requirements and approve without bevacizumab prerequisite; (4) Update prior auth request forms and provider-facing guidance to reflect vision acuity exemptions for DME/DR; (5) Brief clinical review staff and prior auth specialists on distinction between indications (DME/DR have vision exemptions; AMD/RVO do not). Failure to implement these changes will result in inappropriate denials of claims that should be approved under the new criteria, and approval of claims that should require step therapy. No changes needed for billing codes—this is a medical necessity/prior auth policy only, not a coding change.