Eye care · Retina · Medicare Advantage

In Medicare Advantage, the first anti-VEGF dose is a plan decision.

MA plans may require step therapy for Part B drugs on new starts. For 2027, large plans again put bevacizumab or aflibercept first and list several ranibizumab and faricimab products as non-preferred. Here is what plans publish, the federal clocks for exceptions and appeals, and how to run it from the front desk to the auth queue.

By ASP-RCM Editorial, Healthcare RCM Practice · Updated November 6, 2026

Get a free retina denial audit Book a 30-minute MA auth review

365 days

Minimum lookback

42 CFR 422.136: step therapy may apply only to new administrations of Part B drugs

72 hours

Part B drug decision, standard

42 CFR 422.568(b)(3). This clock cannot be extended. Expedited: 24 hours

65 days

To request reconsideration

Calendar days from the date of the denial notice, per CMS

7 days

Part B drug reconsideration, standard

Expedited Part B drug reconsideration: 72 hours

What two national MA plans publish for 2027

From each plan's public 2027 Part B step therapy document, effective 1 January 2027. Other MA plans publish their own lists; check every plan you bill.

Plan	Wet AMD first step	Preferred	Non-preferred	Already on therapy
UnitedHealthcare MA	Repackaged Avastin, then Eylea, Eylea HD or Pavblu	Other retinal conditions: Eylea, Eylea HD, Pavblu	Beovu J0179, Vabysmo J2777, Lucentis J2778, Susvimo J2779, Byooviz Q5124, Cimerli Q5128	Use within the past 365 days counts as continuation; no forced switch
Humana MA	Preferred list, no product order stated on the list	Avastin C9257/J9035, Byooviz Q5124, Eylea J0178, Eylea HD J0177, Lucentis J2778, Pavblu Q5147, Vabysmo J2777	Beovu J0179, Cimerli Q5128, Enzeevu Q5149, Lytenava, Nufymco Q5168, Susvimo, Yesafili Q5155	Step does not apply with a paid claim for the non-preferred drug in the past year

UHC policy IAP.001.32 and the Humana 2027 Part B step therapy preferred drug list. Note how the same drug can be preferred at one plan and non-preferred at another: Vabysmo, Lucentis and Byooviz are examples.

A UnitedHealthcare MA new start for wet AMD, step by step

Each step needs prior authorization for a non-preferred product. UHC says it may deny claims for a non-preferred drug given without one.

Repackaged Avastin first
Unless there is a contraindication or adverse event, start with bevacizumab.
Three doses, then judge
At least 3 doses, given no less often than every 6 weeks, with minimal clinical response opens Eylea, Eylea HD or Pavblu.
Then the non-preferred tier
Vabysmo, Lucentis, Byooviz, Cimerli, Susvimo or Beovu need the bevacizumab trial and a trial of an aflibercept product, or a documented reason.
Or show continuation
Use of the drug within the past 365 days, shown by records or a paid claim, means the patient is not stepped back.

The federal clock on an exception or a denial

Times run from when the plan receives the request. A physician may file on the patient's behalf, and a physician request for expedited reconsideration must be expedited.

Day 0
Auth or step therapy exception request reaches the plan, with chart notes, prior doses and response.
24 to 72 hours
Plan must decide a Part B drug request: 72 hours standard, 24 hours expedited.
Up to day 65
If denied, request reconsideration within 65 calendar days of the notice date.
+7 days
Plan decides a standard Part B drug reconsideration in 7 calendar days (72 hours expedited).
If upheld
The plan must send the case to the Part C Independent Review Entity automatically.

New start or continuation? Get this right at intake

Most avoidable step therapy denials start with a wrong answer to one question: has this patient had this drug in the past 365 days?

Treated as a new start by mistake

Patient changed MA plans and prior doses sit with another payer
Doses given at another practice are not in your chart
Plan system shows no paid claim, so the step is applied
Staff accept the switch instead of sending proof

Continuation proven up front

Prior injection dates and drug pulled from records at intake
Outside records or prior plan EOBs attached to the auth
Lookback date checked against the 365-day rule
Request cites the plan's own continuation wording

How to run it at the front desk and in auth

Front desk: capture the plan

Verify the exact MA plan at every injection visit, not just in January. A plan change can turn a covered continuation into a step.

Auth: one drug map per plan

Keep a 2027 grid of preferred and non-preferred products for each MA plan. The same drug moves tiers between plans.

Clinic: document the response

Record dose dates, interval and response for every bevacizumab or aflibercept dose. That is the evidence a step exception needs.

Billing: hold until auth matches

Check that the billed code and NDC match the approved product before release. A biosimilar swap without a new auth is a denial.

Appeals: date-stamp every notice

The 65-day window runs from the notice date. Log it the day the denial arrives.

Score your anti-VEGF MA workflow

Tick what is true today.

We have each MA plan's 2027 Part B step therapy list on fileIntake records prior anti-VEGF drug and last dose date for every new retina patientAuth requests for non-preferred drugs include dose history and responseWe track the 72-hour and 24-hour decision clocks and chase late answersDenial notices are logged with the 65-day reconsideration deadlineClaims are checked against the approved product code before releaseBiosimilar or product changes trigger a new auth check

0 of 7Under 5? Expect injection write-offs in Medicare Advantage.Get a free retina denial audit

TAKEAWAY

MA plans can step new anti-VEGF starts but must honor a 365-day lookback. Build one drug grid per plan, prove continuation at intake, send dose history with every exception, and work denials inside the 72-hour, 65-day and 7-day federal clocks.

Questions operators ask next

Can a Medicare Advantage plan require step therapy for Eylea or Vabysmo?

Yes, for new starts. Under 42 CFR 422.136 an MA plan may apply step therapy to Part B drugs only for new administrations, using at least a 365-day lookback, after approval by its P&T committee. For 2027, UnitedHealthcare MA puts repackaged Avastin first for wet AMD, and lists Vabysmo as non-preferred. Humana lists Vabysmo as preferred.

How long does an MA plan have to decide a Part B drug request?

Under 42 CFR 422.568(b)(3) the plan must decide a standard Part B drug request no later than 72 hours after receipt, and this period cannot be extended. An expedited Part B drug request must be decided within 24 hours. These clocks apply to step therapy exception and prior authorization requests for anti-VEGF drugs.

What is the deadline to appeal an MA anti-VEGF denial?

CMS says a reconsideration must be requested within 65 calendar days of the date of the denial notice. The enrollee, a representative or the enrollee's physician can file. For a standard Part B drug reconsideration the plan must decide within 7 calendar days, or 72 hours if expedited. If the plan upholds the denial, the case goes automatically to the Independent Review Entity.

Does step therapy apply to a patient already on an anti-VEGF drug?

Not if the patient received the drug within the lookback. Federal rules require at least a 365-day lookback. UnitedHealthcare's 2027 policy says a member cannot be required to change a drug used in the past 365 days, shown by records or a paid claim. Humana exempts patients with a paid claim in the past year.

Are anti-VEGF denials sitting in your MA aging?

Send us 90 days of Medicare Advantage retina denials and auth logs. A senior retina authorization lead sorts them by step therapy, lookback and timing errors, and shows which are still inside the appeal window, in a free 30-minute call with a written gap report after.