Vascular Endothelial Growth Factor Inhibitors for Ocular Indications (CPB 0701, reviewed 2026-07-30)

IMMEDIATE ACTION REQUIRED - By 2026-07-30, billing and clinical staff must implement the following: (1) Precertification Team: Establish precertification protocols for ALL aflibercept formulations (Eylea, Eylea HD, Enzeevu, Pavblu, Eydenzelt, Yesafili, Ahzantive, Opuviz), brolucizumab (Beovu), faricimab (Vabysmo), and ranibizumab products (Lucentis, Susvimo, Cimerli, Byooviz) by calling (866) 752-7021 or faxing (888) 267-3277 BEFORE administering any injection. (2) Billing Team: Update billing system to flag all VEGI injections for mandatory prior authorization and deny claims submitted without precertification documentation. (3) Provider Education: Notify all ophthalmologists and retinal specialists that these medications are restricted to ophthalmologist prescription/consultation only and limited to covered indications: diabetic macular edema, diabetic retinopathy, macular edema following retinal vein occlusion, neovascular wet AMD, retinopathy of prematurity (limited products), myopic choroidal neovascularization (ranibizumab only), choroidal neovascularization variants (bevacizumab only), neovascular glaucoma (bevacizumab only), and polypoidal choroidal vasculopathy (bevacizumab only). (4) Claims Processing: Reject or place on hold all claims for VEGI injections lacking precertification or for non-covered indications marked as 'experimental, investigational, or unproven.' (5) Continuation of Care: For reauthorization requests, require documentation of positive clinical response (improvement/maintenance in BCVA, visual field improvement, or reduced vision decline rate). Failure to obtain precertification will result in automatic claim denial.