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RXMP-14 Retinal Vascular Disease Agents Form

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RXMP-14 Retinal Vascular Disease Agents

Indications

(1) Does the request meet this criterion: LCA as of 10/25/2025: Article - Billing and Coding: Intraocular Bevacizumab (A53008) Medicare Part B 90-Day Transition Period For new Medicare members, a 90-day transition period applies. During this time, if a member is currently on an active? 
(2) Does the request meet this criterion: For new starts, Medicare Part B Step Therapy Criteria must be met in addition to Coverage Criteria before a request may be approved. Avastin (bevacizumab) includes biosimilar products such as Alymsys (bevacizumab-maly) and Vegzelma? 
(3) Does the request meet this criterion: New starts for the above agents require inadequate response to or contraindication to both of the following (a and b):? 
(4) Does the request meet this criterion: Biosimilar Avastin (bevacizumab): Mvasi (bevacizumab-awwb) or Zirabev (bevacizumab-bvzr); and? 
(5) Does the request meet this criterion: Eylea (aflibercept). AND? 

YesNoN/A
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Effective Date

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Last Reviewed

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Original Document

  Reference



Retinal Vascular Disease Agents

Updated on: 12/23/2025

Page 1 of 9 Policy Number RXMP-14 Line of Business Medicaid & Medicare Effective Date 4/1/2019 Revision Date 12/23/2025

Products: Alymsys, Avastin, Beovu, Byooviz, Cimerli, Eylea, Eylea HD, Lucentis, Mvasi, Pavblu, Susvimo, Vabysmo, Vegzelma, Zirabev

Override(s)
Approval Duration
Prior Authorization
1 year

HCPCS Description Medical Benefit: Authorization Required; Pharmacy Benefit: Not covered J9035 Injection, bevacizumab, 10 mg [Avastin] [chemotherapy dose] J7999 Compounded drug not otherwise classified (bevacizumab (compounded prefilled syringe) C9257 Injection, bevacizumab, 0.25mg [Avastin] [intraocular dose]
Q5107 Injection, bevacizumab-awwb, biosimilar, (Mvasi), 10 mg (Preferred) Q5118 Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg (Preferred) Q5126 Injection, bevacizumab-maly, biosimilar, (Alymsys), 10 mg Q5129 Injection, bevacizumab-adcd (Vegzelma), biosimilar, 10 mg
J0179 Injection, brolucizumab-dbll 1 mg (Beovu) J0178 Injection, aflibercept 1 mg (Eylea) (preferred)
Q5147 Injection, aflibercept-ayyh (Pavblu), biosimilar, 1 mg Q5149 Injection, aflibercept-abzv (Enzeevu), biosimilar, 1 mg Q5150 Injection, aflibercept-mrbb (Ahzantive), biosimilar, 1 mg Q5153 Injection, aflibercept-yszy (Opuviz), biosimilar, 1 mg Q5155 Injection, aflibercept-jbvf (Yesafili), biosimilar, 1 mg
J0177 Injection, aflibercept HD 1 mg (Eylea HD) J2778 Injection, ranibizumab 0.1 mg (Lucentis) Q5124 Injection, ranibizumab-nuna biosimilar 0.1 mg (Byooviz) (Preferred) Q5128 Injection, ranibizumab-eqrn (Cimerli), biosimilar, 0.1 mg (Preferred) J2779 Injection, ranibizumab, via intravitreal implant (Susvimo), 0.1 mg C1889 Implantable/insertable device, not otherwise classified (ranibizumab (device) Susvimo J2777 Injection, faricimab-svoa, 0.1 mg (Vabysmo) Medicare (new starts)/ Medicaid preferred agents: Mvasi, Zirabev, Eylea, Byooviz, or Cimerli Medicare Criteria Medicare Part B Coverage Criteria
Review using the most current Local Coverage Determination (LCD), National Coverage Determination (NCD), or Local Coverage Article (LCA) that applies to the Hawaii region. The LCD, NCD, or LCA can be found at: https://www.cms.gov/medicare-coverage-database/search.aspx. • LCA as of 10/25/2025: Article - Billing and Coding: Intraocular Bevacizumab (A53008) Medicare Part B 90-Day Transition Period For new Medicare members, a 90-day transition period applies. During this time, if a member is currently on an active course of the requested treatment, including when furnished by an out-of-network provider, Coverage and Step Therapy do not apply. After the first 90 days of enrollment, Coverage and Step Therapy Criteria must be met for continued coverage. Medicare Part B Step Therapy Criteria • For new starts, Medicare Part B Step Therapy Criteria must be met in addition to Coverage Criteria before a request may be approved.
Avastin (bevacizumab) includes biosimilar products such as Alymsys (bevacizumab-maly) and Vegzelma (bevacizumab-adcd)

Retinal Vascular Disease Agents

Updated on: 12/23/2025

Page 2 of 9 New starts for the above agents: Require inadequate response to or contraindication to biosimilar Avastin (bevacizumab): Mvasi (bevacizumab-awwb) or Zirabev (bevacizumab-adcd) AND prescribed by or in consultation with a retinal specialist. Beovu (brolucizumab-dbll), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-eqrn)

  1. New starts for the above agents require inadequate response to or contraindication to both of the following
    (a and b): a. Biosimilar Avastin (bevacizumab): Mvasi (bevacizumab-awwb) or Zirabev (bevacizumab-bvzr); and b. Eylea (aflibercept). AND
  2. Prescribed by or in consultation with a retinal specialist. Eylea (aflibercept
  3. New starts for the above agent: Mvasi (bevacizumab-awwb) or Zirabev (bevacizumab-bvzr) as alternatives; AND
  4. Prescribed by or in consultation with a retinal specialist. Pavblu (aflibercept-ayyh), Enzeevu (aflibercept-abzv), Ahzantive (aflibercept-mrbb), Opuviz (aflibercept-yszy), Yesafili (aflibercept-jbvf), Eylea HD (aflibercept HD)
  5. New starts for the above agents require inadequate response to or contraindication to all the following (a and b) a. Biosimilar Avastin(bevacizumab): Mvasi (bevacizumab-awwb) or Zirabev (bevacizumab-bvzr); and b. Eylea (aflibercept)
    AND
  6. Prescribed by or in consultation with a retinal specialist Lucentis (ranibizumab), Susvimo (ranibizumab via intravitreal implant), and Vabysmo (faricimab-svoa)
  7. New starts for the above agents require inadequate response to or contraindication to all the following (a, b, and c) a. Biosimilar Avastin (bevacizumab): Mvasi (bevacizumab-awwb) or Zirabev (bevacizumab-bvzr);
    b. Eylea (aflibercept) or Pavblu (aflibercept-ayyh); and c. Biosimilar Lucentis (ranibizumab): Byooviz (ranibizumab-nuna) or Cimerli (ranibizumab-eqrn).
    AND

  8. Prescribed by or in consultation with a retinal specialist.

    Drug Name Approved Indications • Avastin (bevacizumab) including Alymsys (bevacizumab-maly), Vegzelma (bevacizumab-adcd), Mvasi (bevacizumab-awwb), Zirabev (bevacizumab-bvzr) • Eylea (aflibercept) including Pavblu (aflibercept-ayyh), Enzeevu (aflibercept-abzv), Ahzantive (aflibercept-mrbb), Eylea HD (aflibercept HD) • Lucentis (ranibizumab) including Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-eqrn), Susvimo (ranibizumab via intravitreal implant) • Vabysmo (faricimab-svoa)* • Diabetic retinopathy • Macular edema following retinal vein occlusion
    • Avastin (bevacizumab) including Alymsys (bevacizumab-maly), Vegzelma (bevacizumab-adcd), Mvasi (bevacizumab-awwb), Zirabev (bevacizumab-bvzr) • Beovu (brolucizumab-dbll) • Eylea (aflibercept) including Pavblu (aflibercept-ayyh), Enzeevu (aflibercept-abzv), Ahzantive (aflibercept-mrbb), Eylea HD (aflibercept HD) • Neovascular (wet) age-related macular degeneration (AMD)

Retinal Vascular Disease Agents

Updated on: 12/23/2025

Page 3 of 9 Drug Name Approved Indications • Lucentis (ranibizumab) including Byooviz (ranibizumab-nuna) or Cimerli (ranibizumab-eqrn), Susvimo (ranibizumab via intravitreal implant) • Vabysmo (faricimab-svoa) • Lucentis (ranibizumab) including Byooviz (ranibizumab-nuna) or Cimerli (ranibizumab-eqrn) • Myopic Choroidal Neovascularization (mCNV) • Avastin (bevacizumab) including Alymsys (bevacizumab-maly), Vegzelma (bevacizumab-adcd), Mvasi (bevacizumab-awwb) • Beovu (brolucizumab-dbll), • Eylea (aflibercept) including Pavblu (aflibercept-ayyh), Enzeevu (aflibercept-abzv), Ahzantive (aflibercept-mrbb), Eylea HD (aflibercept HD) • Lucentis (ranibizumab) including Cimerli (ranibizumab-eqrn), Susvimo (ranibizumab via intravitreal implant) • Vabysmo (faricimab-svoa) • Diabetic Macular Edema (DME)

• Eylea (aflibercept) • Retinopathy of Prematurity • Avastin (bevacizumab) including Alymsys (bevacizumab-maly), Vegzelma (bevacizumab-adcd), Mvasi (bevacizumab-awwb), Zirabev (bevacizumab-bvzr) • Proliferative diabetic retinopathy • Choroidal neovascularization (CNV) including myopic choroidal neovascularirazation (mCNV), angioid streaks, choroiditis [including choroiditis secondary to ocular histoplasmosis], idiopathic degenerative myopia, retinal dystrophies, rubeosis iridis, pseudoxanthoma elasticum, and trauma)
• Neovascular glaucoma
• Retinopathy of prematurity • Polypoidal choroidal vasculopathy

  • Only covers macular edema following retinal vein occlusion

    Products Avastin, Mvasi (preferred), Alymsys, Vegzelma, Zirabev (preferred) LOB Medicare/Medicaid
    Approval Length Initial 6 months Override Type PA, QL Note: Concurrent use of more than one VEGF inhibitor in the same eye is considered experimental and investigational because the safety and effectiveness of combinational use of VEGF inhibitors for ocular indications have not been established. Approval Criteria

    1. The request is for one of the following diagnoses: a. Diabetic macular edema; b. Neovascular (wet) age-related macular degeneration (AMD); c. Macular edema following retinal vein occlusion; d. Proliferative diabetic retinopathy; e. Choroidal neovascularization (CNV) (including myopic choroidal neovascularization (mCNV), angioid streaks, choroiditis [including choroiditis secondary to ocular histoplasmosis], idiopathic degenerative myopia, retinal dystrophies, rubeosis iridis, pseudoxanthoma elasticum, and trauma); f. Neovascular glaucoma; g. Retinopathy of prematurity; or h. Polypoidal choroidal vasculopathy.

Retinal Vascular Disease Agents

Updated on: 12/23/2025

Page 4 of 9 AND

  1. Prescribed by or in consultation with a retinal specialist; AND

  2. For Alymsys (bevacizumab-maly), and Vegzelma (bevacizumab-adcd): Inadequate response to or contraindication to biosimilars Mvasi (bevacizumab-awwb) or Zirabev (bevacizumab-bvzr).

    Products Eylea (preferred), Pavblu, Enzeevu, Ahzantive, Opuviz, Yesafili LOB Medicare/Medicaid
    Approval Length Initial 6 months Override Type PA, QL Note: Concurrent use of more than one VEGF inhibitor in the same eye is considered experimental and investigational because the safety and effectiveness of combinational use of VEGF inhibitors for ocular indications have not been established. Approval Criteria – Initial

  3. The request is for one of the following diagnoses: a. Diabetic macular edema; b. Diabetic retinopathy; c. Macular edema following retinal vein occlusion; or d. Neovascular (wet) age-related macular degeneration (AMD). AND
  4. Prescribed by or in consultation with a retinal specialist; AND
  5. Inadequate response to or contraindication to Avastin (bevacizumab) or biosimilar; AND
  6. For Eylea vials member must have diagnosis of Retinopathy of Prematurity (ROP) AND all the following:
    1) One of the following:
    • Patient gestational age at birth is less than or equal to 32 weeks; or • Patient birth weight less than or equal to 1500 grams. 2) Patients weight greater than 800 grams on day of treatment; AND 3) Retinopathy of prematurity (ROP) is present in at least one eye with one of the following classifications:
    • ROP zone 1, stage 1 plus, 2 plus, 3, or 3 plus; • ROP zone 2, stage 2 plus or 3 plus; or • AP - ROP (aggressive posterior ROP). AND

  7. For Eylea HD (aflibercept HD) see Continuation of Care, must have 1 year trial of Eylea (aflibercept).

    Products Beovu LOB Medicare/Medicaid
    Approval Length Initial 6 months Override Type PA, QL Note: Concurrent use of more than one VEGF inhibitor in the same eye is considered experimental and investigational because the safety and effectiveness of combinational use of VEGF inhibitors for ocular indications have not been established.

    Approval Criteria

  8. The request is for one of the following diagnoses: a. Neovascular (Wet) Age-Related Macular Degeneration; or b. Diabetic Macular Edema AND
  9. Prescribed by or in consultation with a retinal specialist; AND
  10. Inadequate response to or contraindication to Avastin (bevacizumab) or its biosimilars Mvasi (bevacizumab- awwb) or Zirabev (bevacizumab-bvzr); AND

Retinal Vascular Disease Agents

Updated on: 12/23/2025

Page 5 of 9

  1. Inadequate response to or contraindication to Eylea (aflibercept)

    Products Vabysmo
    LOB Medicaid/Medicare Approval Length Initial 6 months Override Type PA, QL Note: Concurrent use of more than one VEGF inhibitor in the same eye is considered experimental and investigational because the safety and effectiveness of combinational use of VEGF inhibitors for ocular indications have not been established.

    Approval Criteria

  2. The request is for one of the following diagnoses: a. Diabetic Macular Edema;
    b. Neovascular (Wet) Age-Related Macular Degeneration; or
    c. Macular Edema Following Retinal Vein Occlusion AND
  3. Prescribed by or in consultation with a retinal specialist; AND
  4. Inadequate response to, intolerable adverse event to, or has a contraindication for Avastin (bevacizumab) or its biosimilars Mvasi (bevacizumab-awwb) or Zirabev (bevacizumab-bvzr); AND

  5. Inadequate response to or contraindication to Eylea (aflibercept).

    Products Lucentis (preferred), Cimerli (preferred), Byooviz LOB Medicare/Medicaid
    Approval Length Initial 6 months Override Type PA, QL Note: Concurrent use of more than one VEGF inhibitor in the same eye is considered experimental and investigational because the safety and effectiveness of combinational use of VEGF inhibitors for ocular indications have not been established.

    Approval Criteria

  6. The request is for one of the following diagnoses: a. Diabetic macular edema b. Diabetic retinopathy c. Macular edema following retinal vein occlusion d. Neovascular (wet) age-related macular degeneration (AMD) e. Myopic choroidal neovascularization (FDA indication for Lucentis & biosimilar only)
    AND
  7. Prescribed by or in consultation with a retinal specialist; AND
  8. Inadequate response to or contraindication to Avastin (bevacizumab) or its biosimilars Mvasi (bevacizumab- awwb) or Zirabev (bevacizumab-bvzr); AND
  9. Inadequate response to or contraindication to Eylea (aflibercept); AND

  10. For Lucentis (ranibizumab) and Vabysmo (faricimab-svoa): Inadequate response to or contraindication to Byooviz (ranibizumab-nuna) or Cimerli (ranibizumab-eqrn).

    Products Susvimo LOB Medicare/Medicaid
    Approval Length Initial 6 months Override Type PA, QL

Retinal Vascular Disease Agents

Updated on: 12/23/2025

Page 6 of 9 Note: Concurrent use of more than one VEGF inhibitor in the same eye is considered experimental and investigational because the safety and effectiveness of combinational use of VEGF inhibitors for ocular indications have not been established.

Approval Criteria

  1. The request is for one of the following diagnoses: a. Diabetic retinopathy;
    b. Macular edema following retinal vein occlusion;
    c. Neovascular (wet) age-related macular degeneration (AMD); or
    d. Diabetic Macular Edema
    AND
  2. Prescribed by or in consultation with a retinal specialist; AND
  3. The member has previously responded to at least two intravitreal injections of a Vascular Endothelial Growth Factor (VEGF) inhibitor (e.g., Avastin/Mvasi/Zirabev, Eylea) within the past 6 months; AND
  4. Inadequate response to or contraindication to Lucentis (ranibizumab) or its biosimilars [Byooviz (ranibizumab- nuna) or Cimerli (ranibizumab-eqrn)]; AND

  5. The request will be used in conjunction with the Susvimo ocular implant

    Susvimo (ranibizumab) ocular implant may be approved when used with intravitreal Susvimo (ranibizumab injection) for treatment of neovascular (wet) age-related macular degeneration, diabetic retinopathy, macular edema following retinal vein occlusion and when criteria are met for Susvimo (ranibizumab) intravitreal injection.

    Products Avastin, Alymsys, Mvasi, Vegzelma, Zirabev; Beovu; Eylea, Eylea HD, Pavblu; Lucentis, Byoovi, Cimerli, Susvimo; Vabysmo LOB Medicare/Medicaid
    Diagnosis All Approval Length Renewal 12 months Override Type PA, QL

  6. Prescribed by or in consultation with a retinal specialist; AND
  7. The member has demonstrated a positive clinical response to therapy (e.g., improvement or maintenance in best corrected visual acuity [BCVA] or visual field, or a reduction in the rate of vision decline or the risk of more severe vision loss); AND
  8. For Beovu (brolucizumab-dbll), Byooviz (ranibizumab-nuna), Cimerli (ranibizumab-eqrn):
    a. Inadequate response to, intolerable adverse event to, or has a contraindication to Avastin or its biosimilars [Mvasi (bevacizumab-awwb)) or Zirabev (bevacizumab-bvzr)]; AND
  9. For Eylea HD (aflibercept HD): Both of the following are met: a. The member must have a diagnosis of one of the following: age-related macular degeneration, diabetic macular edema, diabetic retinopathy, macular edema following retinal vein occlusion; and
    b. The member must have been on Eylea (aflibercept) or its biosimilar Pavblu (aflibercept-ayyh) for 1 year. AND
  10. For Lucentis (ranibizumab), Susvimo (ranibizumab via intravitreal implant), and Vabysmo (faricimab-svoa): All the following are met: a. Inadequate response to or contraindication to Avastin (bevacizumab) or biosimilars [Mvasi (bevacizumab- awwb) or Zirabev (bevacizumab-bvzr)];
    b. Inadequate response to or contraindication to Eylea (aflibercept) or its biosimilar Pavblu (aflibercept-ayyh); and c. For Susvimo (ranibizumab via intravitreal implant) and Vabysmo (faricimab-svoa): Inadequate response to or contraindication to Lucentis (ranibizumab) or its biosimilars [Byooviz (ranibizumab-nuna) or Cimerli (ranibizumab-eqrn)].
  11. Eylea (aflibercept) vials for Retinopathy of Prematurity (ROP): Both of the following are met:

Retinal Vascular Disease Agents

Updated on: 12/23/2025

Page 7 of 9 a. Documentation of positive clinical response to therapy as evidenced by the absence of active ROP and unfavorable structural outcomes (e.g., retinal detachment, macular dragging, macular fold, retrolental opacity); and b. Prescribed by or in consultation with a retinal specialist.

Exclusion: Active intraocular inflammation ocular or periocular infections

FDA Indications & Dosing Drug Name Indication Dosing/Administration Avastin (bevacizumab) & biosimilars Macular edema due to diabetes mellitus 1.25mg (0.05mL) at baseline and repeat every 4 weeks depending on ophthalmologic response (off-label dosage) Age related macular degeneration
Macular edema following retinal occlusion
Proliferative diabetic retinopathy
Choroidal neovascularization (CNV) (including myopic choroidal neovascularization (mCNV), angioid streaks, choroiditis [including choroiditis secondary to ocular histoplasmosis], idiopathic degenerative
myopia, retinal dystrophies,
rubeosis iridis, pseudoxanthoma elasticum, and trauma) Neovascular glaucoma Polypoidal choroidal vasculopathy Avastin (bevacizumab) & biosimilars Retinopathy of prematurity ▪ Conventional dose: 0.625mg as single dose in the affect eyes
▪ Low dose: 0.0625mg to 0.5mg has been reported in literature Beovu (brolucizumab- dbll) Exudative age-related macular degeneration ▪ Initial, 6mg once monthly (~25 to 31 days) for 3 months
▪ Maintenance, 6mg once every 8 to 12 weeks Macular edema due to diabetes mellitus ▪ Initial, 6mg every 6 weeks (~39 to 45 days) for 5 doses ▪ Maintenance, 6mg once every 8 to 12 weeks Eylea (aflibercept) & biosimilars Neovascular (Wet) Age- Related Macular Degeneration (AMD) 2mg (0.05mL) every 4 weeks for 12 weeks, then 2mg (0.05mL) every 8 weeks some may require every 4-week dosing after the first 12 weeks some may extend to every 12 weeks after 1 year Macular Edema following Retinal Vein Occlusion (RVO) 2mg (0.05mL) every 4 weeks Diabetic Macular Edema (DME) 2mg (0.05mL) every 4 weeks for 5 injections, then 2mg (0.05mL) every 8 weeks however, some may require every 4-week dosing after the first 20 weeks Diabetic Retinopathy
Eylea (aflibercept) Retinopathy of Prematurity 0.4mg as a single injection in the affected eye(s), may repeat dose(s) after a minimum interval of 10 days.

Retinal Vascular Disease Agents

Updated on: 12/23/2025

Page 8 of 9 Drug Name Indication Dosing/Administration Eylea HD (aflibercept HD) Age-related macular degeneration, diabetic macular edema, diabetic retinopathy 8mg (0.07mL) once every 4 weeks (~21 to 35 days) for the first 3 doses, followed by 8mg (0.07mL) once every 8 to 16 weeks +/- 1 week. Lucentis (ranibizumab)

Cimerli (ranibizumab- eqrn)

Exudative age-related macular degeneration ▪ 0.5 mg (0.05 mL of 10 mg/mL solution) once a month (~28 days) (FDA dosage) ▪ (Dose adjustment) After 3 consecutive monthly doses (if using 0.5mg dose), dosing interval may be extended (e.g., by 2 to 4 weeks) based on response with regular assessment (i.e., “treat and extend” strategy). ▪ Note: A regimen averaging 4 to 5 doses over 9 months is expected to maintain visual acuity and an every-3-month dosing regimen has reportedly resulted in an approximately 5 letter (1 line) loss of visual acuity over 9 months, as compared to monthly dosing, which may result in an additional approximately 1 to 2 letter gain. Macular edema due to diabetes mellitus ▪ 0.3mg (0.05 mL of 6 mg/mL solution) once monthly (~28 days); in clinical trials, monthly doses of 0.5mg were also studied (FDA dosage) ▪ (Dose adjustment) After 3 consecutive monthly doses (if using 0.5mg dose), dosing interval may be extended (e.g., by 2 to 4 weeks) based on response with regular assessment (i.e., “treat and extend” strategy). Diabetic Retinopathy 0.3mg (0.05mL) once a month (~ 28 days) Lucentis (ranibizumab) Cimerli (ranibizumab- eqrn) Byooviz (ranibizumab- nuna Macular retinal edema following retinal vein occlusion ▪ 0.5 mg (0.05 mL of 10 mg/mL solution) once a month (~28 days) ▪ (Dose adjustment) After 3 consecutive monthly doses (if using 0.5mg dose), dosing interval may be extended (e.g., by 2 to 4 weeks) based on response with regular assessment (i.e., “treat and extend” strategy). Myopic choroidal neovascularization ▪ 0.5 mg (0.05 mL of a 10 mg/mL solution) once a month (~28 days) for up to 3 months; may retreat if needed (FDA dosage) ▪ Re-treatment, may be guided by visual acuity stabilization or guided by disease activity (off-label dosage) Susvimo (ranibizumab via intravitreal implant) Exudative age-related macular degeneration Macular edema due to diabetes
Diabetic Retinopathy
▪ 2mg (0.02mL of 100mg/mL) continuously via ocular implant with refills administered every 24 weeks (~6 months)
▪ Supplemental injections (Lucentis) of 0.5mg (0.05mL of 10mg/mL) may be administered to the affected eye while implant is in place if needed Vabysmo (faricimab-svoa) Exudative age-related macular degeneration ▪ Initial, 6mg once every 4 weeks (~28 days) for doses
▪ Subsequent doses:
o Every 8 weeks regimen: 6mg on weeks 20, 28, 36, and 44 o Every 12 weeks regimen: 6mg on weeks 24, 36, and 48 o Every 16 weeks regimen: 6mg on weeks 28 and 44
Macular edema due to diabetes mellitus ▪ Initial, 6mg once every 4 weeks (~28 days) for 6 doses ▪ Subsequent doses, 6mg once every 8 weeks
▪ Variable interval regimen: o Initial, 6mg once every 4 weeks (~28 days) for at least 4 doses

Retinal Vascular Disease Agents

Updated on: 12/23/2025

Page 9 of 9 Drug Name Indication Dosing/Administration o Subsequent doses, 6mg every 4 to 16 weeks (based on visual assessments)
Macular edema following retinal vein occlusions 6mg intravitreally once every 4 weeks (~28 days) for 6 months

References

  1. OptumRx criteria, accessed May 2023.
  2. Micromedex DRUGDEX, accessed May 2023

  3. IPD Analytics & CodeSource, accessed May 2023.

    Change History:

  4. 4/1/2019, 5/11/2020 HB, 8/8/2022 PH; 5/27/2023: updated criteria, added ST and preferred agents HB; 10/3/23 PH/HB: added retinal specialist as alternative to bevacizumab biosimilars
  5. 3/24/25,5/12/2025: updated criteria, added ST, new drugs, and preferred agents HB,AP,HH,YM
  6. 6/11/25 HH/YM: updated criteria, Eylea biosimilar
  7. 7/14/25 AP/YM: updated FDA indication/dosing, layout, approval duration
  8. 12/23/25 AP: Added preferred agents
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