Navigating Eylea (Aflibercept) Prior Authorization Policies Across Major U.S. Payers

Eylea (aflibercept) is a leading anti-VEGF (vascular endothelial growth factor) therapy indicated for retinal conditions such as neovascular (wet) age-related macular degeneration (AMD), diabetic macular edema (DME), diabetic retinopathy (DR), macular edema following retinal vein occlusion (RVO), and retinopathy of prematurity (ROP). As a high-cost specialty drug administered via intravitreal injection, Eylea is often subject to strict prior authorization (PA) guidelines due to its significant impact on payer budgets. This article explores the latest PA policies across key payers—including Aetna, Medicare, UnitedHealthcare, Cigna, and Blue Cross Blue Shield (BCBS)—and provides context around drug delivery, market dynamics, and utilization trends.

Prior Authorization Requirements by Major Payers

Aetna

Aetna classifies Eylea and Eylea HD as non-preferred drugs for Medicare Advantage plans, favoring bevacizumab (Avastin) and biosimilars. Approval for Eylea typically requires:

• A documented failure, intolerance, or contraindication to Avastin.

• Evidence of sufficient visual acuity loss, often 20/50 or worse.

• Clinical documentation aligned with FDA labeling for conditions like wet AMD or DME.

Medicare

Under Medicare Part B, Eylea is generally reimbursed as a medical benefit. However, Medicare Advantage plans often implement step therapy policies:

• Patients must try and fail lower-cost alternatives (e.g., Avastin) first.

• Detailed clinical documentation supporting the use of Eylea is required.

• Step therapy protocols have expanded significantly as of 2025.

UnitedHealthcare (UHC)

UHC enforces PA across both commercial and Medicare Advantage lines of business. Their typical requirements include:

• Use of Avastin before Eylea approval unless contraindicated.

• Submission of clinical documentation such as treatment history and visual acuity results.

• Policies aligned with their Part B Step Therapy Program guidelines.

Cigna

Cigna’s Eylea coverage extends to DME, DR, RVO, and wet AMD but requires PA:

• Indications must meet Cigna’s clinical criteria (e.g., retinal thickening, acuity worse than 20/50).

• Evidence of disease severity and prior treatment attempts must be documented.

Blue Cross Blue Shield (BCBS)

BCBS entities vary by state, but common patterns include:

• Step therapy requiring Avastin use first.

• Prior authorization with quantity limits and FDA-aligned dosing schedules.

• Formularies often include biosimilars and preferred alternatives, depending on regional policies.

Drug Delivery, Utilization, and Market Trends

Administration and Dosing

Eylea is delivered via intravitreal injection, with typical regimens including:

• 2 mg every 4 weeks for 12 weeks, then 2 mg every 8 weeks for wet AMD.

• Eylea HD offers a higher dose (8 mg), allowing for longer intervals between treatments.

Spending and Cost Trends

Eylea is consistently ranked among the top-spending drugs under Medicare Part B:

• It accounts for billions in annual expenditures, largely due to the growing prevalence of retinal diseases.

• Biosimilars like Pavblu (aflibercept-mrbb) may reduce spending, but uptake varies.

Patient Volume and Demand

• Rising incidence of AMD and diabetic eye conditions is driving higher patient volumes.

• The aging U.S. population is expected to further increase demand for anti-VEGF treatments.

• Access is sometimes delayed due to administrative hurdles from PA and step therapy.

Conclusion

Eylea remains a cornerstone therapy for vision-threatening retinal diseases, delivering substantial clinical benefits. However, its high cost and expanding payer controls mean providers must be diligent in navigating complex prior authorization requirements. Familiarity with individual payer policies, thorough documentation, and readiness to justify medical necessity are key to ensuring timely patient access to this vital therapy.