Vascular Endothelial Growth Factor Inhibitors for Ocular and Selected Indications — CPB 0701 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0701 covering VEGF inhibitors for ocular indications, effective March 17, 2026. Here's what changes for billing teams.

This update to the Aetna VEGF inhibitor coverage policy expands the biosimilar drug list and refines medical necessity criteria across a broad set of retinal conditions. If your practice bills CPT 67028 for intravitreal injections—or uses HCPCS codes J0178, J0177, J0179, J2777, or any of the aflibercept and bevacizumab biosimilar Q-codes—this policy governs your reimbursement on commercial plans. With 20 HCPCS codes and nine CPT codes in scope, the financial exposure here is significant.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Vascular Endothelial Growth Factor Inhibitors for Ocular and Selected Indications
Policy Code	CPB 0701
Change Type	Modified
Effective Date	March 17, 2026
Impact Level	High
Specialties Affected	Ophthalmology, Retina, Oncology (select indications), Optometry
Key Action	Confirm precertification is in place for all branded and biosimilar VEGF inhibitors before billing CPT 67028 on commercial Aetna plans

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Aetna VEGF Inhibitor Coverage Criteria and Medical Necessity Requirements 2026

The Aetna VEGF inhibitor coverage policy under CPB 0701 covers intravitreal injections billed under CPT 67028 for a defined list of retinal conditions. Medical necessity is not presumed—you must establish it against specific criteria before the first injection and again at reauthorization.

Precertification is mandatory for all of the following agents on commercial plans: aflibercept (Eylea, Eylea HD), and all seven approved aflibercept biosimilars—aflibercept-abzv (Enzeevu, Q5149), aflibercept-ayyh (Pavblu, Q5147), aflibercept-boav (Eydenzelt), aflibercept-jbvf (Yesafili, Q5155), aflibercept-mrbb (Ahzantive, Q5150), aflibercept-yszy (Opuviz, Q5153)—plus brolucizumab-dbll (Beovu, J0179), faricimab-svoa (Vabysmo, J2777), ranibizumab (Lucentis), ranibizumab (Susvimo, J2779), ranibizumab-eqrn (Cimerli, Q5128), and ranibizumab-nuna (Byooviz, Q5124). Call (866) 752-7021 or fax (888) 267-3277 to initiate prior authorization.

Bevacizumab and its biosimilars—Avastin (C9257, J9035), Mvasi (Q5107), Zirabev (Q5118), Alymsys (Q5126), Vegzelma (Q5129), Jobevne (Q5160), and Avzivi/Avzini (see note below)—do not carry the same precertification mandate under this policy. That said, always verify plan-level requirements. Some Aetna commercial plan designs add prior auth requirements that go beyond the base CPB.

Source note: The policy data uses both "Avzivi" and "Avzini" to refer to bevacizumab-tnjn. It is unclear which spelling is correct based on the source reviewed. Verify the current spelling against the published Aetna CPB 0701 policy before using it in documentation or claims.

Aflibercept: Initial Approval Criteria

Aetna considers aflibercept and its biosimilars (billed under J0178 or J0177 for Eylea HD) medically necessary for five indications:

Everything outside that list is considered not medically necessary or experimental. There are no gray areas here.

Aflibercept: Continuation of Therapy

Reauthorization requires documented positive clinical response. Aetna defines that as 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. If the chart doesn't show that, expect a denial.

Build that documentation into your reauthorization workflow now. A missing BCVA measurement is an easy target for a claim denial at renewal.

Note on continuation criteria for other agents: The source summary reviewed for this post covers continuation of therapy criteria for aflibercept only. Continuation criteria for bevacizumab, brolucizumab, faricimab, and ranibizumab were not fully available in the truncated source. Review the full CPB 0701 policy document for those criteria before managing reauthorization for those agents.

Bevacizumab: Initial Approval Criteria

The bevacizumab section covers a broader indication list. Aetna considers intravitreal bevacizumab and its biosimilars medically necessary for:

Important: The policy summary reviewed was truncated at the choroidal neovascularization entry. Additional bevacizumab indications may exist in the full policy. Verify the complete indication list from the full CPB 0701 document before submitting claims.

Note that bevacizumab (Avastin) used intraocularly bills under C9257 at the 0.25 mg intraocular dose—not J9035, which is the 10 mg chemotherapy dose. If your charge capture is pulling the wrong bevacizumab code based on drug name alone, fix that before your next claim goes out.

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Aetna VEGF Inhibitor Exclusions and Non-Covered Indications

Any indication not explicitly listed in CPB 0701 is not covered under this policy. Aetna classifies off-label uses as experimental, investigational, or unproven.

CPT 66030 (injection into the anterior chamber) and CPT 68200 (subconjunctival injection) are explicitly listed as not covered for indications in this CPB. If you're injecting in those anatomical locations, you cannot use this policy to support medical necessity—regardless of the drug.

If your retina practice bills for anything beyond the five aflibercept indications or the bevacizumab indications listed above, expect a denial without a strong prior authorization argument. Talk to your compliance officer before submitting off-label claims on commercial Aetna plans.

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Coverage Indications at a Glance

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Aetna VEGF Inhibitor Billing Guidelines and Action Items 2026

Here's what your billing team needs to do before the March 17, 2026 effective date and after.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for VEGF Inhibitors Under CPB 0701

Covered CPT Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
67028	CPT	Intravitreal injection of a pharmacologic agent (separate procedure)

Not Covered CPT Codes (For CPB 0701 Indications)

Code	Type	Description	Reason Copy
66030	CPT	Injection, anterior chamber of eye (separate procedure); medication	Explicitly not covered for indications listed in CPB 0701
68200	CPT	Subconjunctival injection	Explicitly not covered for indications listed in CPB 0701

Covered HCPCS Codes — Aflibercept and Biosimilars

Covered HCPCS Codes — Brolucizumab, Faricimab, Ranibizumab

Covered HCPCS Codes — Bevacizumab and Biosimilars

Source note on J2778: The source policy data groups J2778 (injection, ranibizumab, 0.1 mg) with the bevacizumab agents rather than the ranibizumab precertification group. This may reflect a data anomaly in the source. Verify J2778's correct grouping and precertification requirements against the full published CPB 0701 before billing.

Key ICD-10-CM Diagnosis Codes

The full CPB 0701 ICD-10 list runs to 1,787 codes. Below are the primary diagnosis codes most relevant to VEGF inhibitor billing. Pull the complete list from the Aetna policy source before submitting claims.

The ICD-10 scope of this policy is unusually wide. The inclusion of oncology codes (C19, C53–C55, C56) reflects the selected systemic indications referenced in the policy title. If your practice doesn't treat those conditions, those codes won't apply—but confirm your diagnosis codes against the full list at app.payerpolicy.org/p/aetna/0701 before the effective date.

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