Aflibercept and Associated Biosimilar(s)

This policy covers aflibercept and associated biosimilars (intravitreal products such as Eylea and Pavblu) for ocular neovascular and edema conditions including neovascular (wet) AMD, diabetic macular edema, diabetic retinopathy, macular edema from retinal vein occlusion, retinopathy of prematurity, and choroidal neovascularization. Coverage generally requires prior trial and failure of intravitreal bevacizumab (or a documented contraindication or verified bevacizumab shortage/recall), continuation only if the member demonstrates clinical benefit with dosing per an authoritative source, off‑label uses must be supported by an accepted compendium or two peer‑reviewed articles, and benefits are subject to the member’s plan and applicable state/HCSC rules.

"Therapies must be proven effective for the relevant diagnosis or procedure to be considered for coverage."

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