By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

How to Get Eylea and Lucentis Covered by Blue Cross Blue Shield of Texas: Complete Prior Authorization Guide

Quick Answer: Getting Eylea/Lucentis Approved by BCBS Texas

Blue Cross Blue Shield of Texas requires prior authorization for Eylea (aflibercept) and Lucentis (ranibizumab). Most plans require step therapy with bevacizumab (Avastin) first, unless contraindicated. Submit requests through Availity Essentials with OCT imaging, visual acuity records, and diagnosis documentation. Standard decisions take 30 days; urgent cases get 72-hour review. If denied, you have 60 days to appeal internally, then can request external review through Texas Department of Insurance.

First step today: Verify your plan type and check if Eylea/Lucentis requires PA by calling the number on your member ID card.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Expectations
  6. If More Information is Requested
  7. If Your Request is Denied
  8. Renewal and Re-authorization
  9. Appeals Process in Texas
  10. Cost-Saving Options
  11. FAQ

What This Guide Covers

This guide helps Texas patients and their eye doctors navigate Blue Cross Blue Shield of Texas (BCBSTX) prior authorization for Eylea (aflibercept) and Lucentis (ranibizumab)—two anti-VEGF injections used to treat wet age-related macular degeneration (AMD), diabetic macular edema, and related retinal conditions.

These medications cost $1,200-$2,500 per injection and require careful documentation to secure coverage. We'll walk through the exact forms, timelines, and appeal strategies specific to Texas.

Note: This guide applies to BCBSTX commercial plans. Medicare Advantage and Medicaid managed care may have different requirements.

Before You Start: Plan Verification

Step 1: Identify Your Plan Type

Call the customer service number on your BCBSTX member ID card to confirm:

  • Whether your plan requires prior authorization for Eylea/Lucentis
  • If step therapy with bevacizumab (Avastin) is required first
  • Your specific formulary tier and copay

Special case: If you have HealthSelect of Texas (state employee plan), prior authorizations are not required as of September 2024, but you'll need a PCP referral on file.

Step 2: Verify Medical vs. Pharmacy Benefit

Eylea and Lucentis are typically covered under the medical benefit (not pharmacy) since they're provider-administered injections. Your retina specialist will need to:

Gather Required Documentation

Medical Necessity Checklist

Your eye doctor will need to provide:

Diagnosis Documentation:

  • ICD-10 codes for your specific condition (e.g., H35.32 for wet AMD)
  • Recent OCT imaging showing retinal fluid or macular edema
  • Visual acuity measurements for both eyes
  • Color fundus photography or fluorescein angiography (if available)

Treatment History:

  • Documentation of prior therapies tried and failed (especially bevacizumab if step therapy applies)
  • Reasons for treatment failure or contraindications
  • Any adverse reactions to previous anti-VEGF treatments

Clinical Justification:

  • Letter of medical necessity explaining why Eylea or Lucentis is specifically needed
  • Treatment goals and expected outcomes
  • Monitoring plan and injection schedule

Submit Your Prior Authorization Request

For Providers: Submission Methods

Primary Method: Availity Essentials portal Alternative: Phone number on patient's member ID card Forms: Access current PA forms through the BCBSTX provider portal

Step Therapy Override Criteria

If your plan requires trying bevacizumab (Avastin) first, you can request an override by documenting:

  • Allergy or hypersensitivity to bevacizumab
  • Previous treatment failure with bevacizumab
  • Medical contraindications that make bevacizumab inappropriate
  • Urgent clinical need where delay could worsen vision
From our advocates: We've seen override requests succeed most often when providers include specific details about previous bevacizumab treatment—exact dates, number of injections, and measurable lack of response on OCT imaging. Generic statements about "treatment failure" are less persuasive than documented evidence.

Follow-Up and Timeline Expectations

Standard Review Process

  • Standard PA decision: 30 days from complete submission
  • Urgent/expedited review: 72 hours if delay could jeopardize health
  • Incomplete submissions: BCBSTX will request additional information within 14 days

What to Track

Keep records of:

  • PA request submission date and reference number
  • Any requests for additional information
  • Decision letters (approval or denial)
  • Appeal deadlines if denied

If More Information is Requested

BCBSTX may ask for additional clinical documentation such as:

  • More recent OCT scans
  • Detailed treatment history from previous providers
  • Specialist consultation notes
  • Laboratory results (for diabetic patients)

Response timeline: You typically have 30 days to provide requested information. Submit everything at once to avoid delays.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Step therapy not completed Document bevacizumab trial/failure or contraindication
Insufficient visual acuity documentation Provide detailed VA measurements and OCT evidence
Diagnosis not supported Submit additional imaging and specialist notes
Frequency/quantity limits exceeded Justify treatment schedule with clinical guidelines

Renewal and Re-authorization

Most PA approvals for Eylea/Lucentis are granted for 6-12 months. Plan ahead by:

  • Calendar reminder: Set for 30 days before expiration
  • Gather updated records: Recent OCT scans, visual acuity measurements, treatment response documentation
  • Document continued medical necessity: Show ongoing need and response to treatment

Appeals Process in Texas

Internal Appeal Timeline

If your PA is denied, you have 60 days to file an internal appeal with BCBSTX:

How to appeal:

  • Call 1-888-657-6061 for pharmacy-related appeals
  • Submit online through MyPrime.com or provider portal
  • Mail written appeal to address provided in denial letter

Decision timeframe:

  • Standard appeals: 30 days
  • Urgent appeals: 72 hours

External Review (IRO)

If BCBSTX upholds the denial, you can request an Independent Review Organization (IRO) review:

  • Deadline: 120 days from final internal denial
  • Cost: Free (BCBSTX pays for the review)
  • Timeline: 20 days for standard review, 5 days for urgent cases
  • Binding decision: If IRO approves, BCBSTX must cover the treatment

Texas Department of Insurance help: Call 1-800-252-3439 for assistance with the appeals process.

Cost-Saving Options

While working through the PA process, explore these options:

Manufacturer Support:

Foundation Grants:

  • Patient Access Network Foundation
  • Good Days (formerly Chronic Disease Fund)
  • The Assistance Fund

State Resources:

  • Texas Department of Insurance consumer assistance: 1-800-252-3439

FAQ

Q: How long does BCBS Texas prior authorization take? A: Standard PA decisions take up to 30 days. Urgent cases are decided within 72 hours if delay could seriously harm your health.

Q: What if Eylea or Lucentis isn't on my formulary? A: You can request a formulary exception by demonstrating medical necessity. Your doctor will need to show why preferred alternatives aren't appropriate.

Q: Can I get an expedited appeal in Texas? A: Yes, if waiting for the standard appeal timeline could seriously jeopardize your health. Both internal and external (IRO) appeals can be expedited.

Q: Does step therapy apply if I tried bevacizumab with a different insurer? A: Previous treatment history with other insurers should count toward step therapy requirements. Provide documentation from your previous provider.

Q: What's the difference between Eylea and Lucentis coverage? A: Both require prior authorization and typically have similar coverage criteria. The choice between them is usually based on clinical factors rather than insurance preferences.

Q: Can I appeal directly to the state if BCBS denies my request? A: You must complete BCBS's internal appeal process first, then you can request external review through an Independent Review Organization contracted by the Texas Department of Insurance.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific requirements—helping you get the medications you need faster.

For complex cases or repeated denials, consider working with a platform like Counterforce Health that specializes in prior authorization appeals and can help navigate the specific requirements of your BCBSTX plan.

Sources & Further Reading

Disclaimer: This guide is for informational purposes only and does not constitute medical or legal advice. Insurance policies and coverage criteria can change. Always verify current requirements with your specific BCBS Texas plan and consult with your healthcare provider about treatment decisions. For personalized assistance with appeals or complex cases, consider consulting with qualified professionals who specialize in insurance advocacy.

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