Payer PolicyActive
Aflibercept (Eylea®) Injection
EVICORE-MEDICAL_DRUG-77F1FC7A
EviCore by Evernorth
Effective: September 1, 2022
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Eylea (aflibercept) is covered for FDA‑approved ophthalmic indications (neovascular AMD, RVO‑related macular edema, DME, DR) and select compendial off‑label neovascular ocular uses; treatments outside these listed indications are excluded. Approval (up to 12 months) requires a documented diagnosis, administration by or under an ophthalmologist, and documentation supporting adherence to indication‑specific dosing/frequency (AMD: 2 mg q4wk ×3 then q8wk; RVO: 2 mg q4wk; DME/DR: 2 mg q4wk ×5 then q8wk).
Coverage Criteria Preview
Key requirements from the full policy
"Neovascular (wet) age-related macular degeneration (AMD)"
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