Q5170 Inj, aflibercept-boav, 1 mgInjection, aflibercept-boav (eydenzelt), biosimilar, 1 mg
Status E: excluded from the PFS by regulation.
15 of 15 payer prior-auth lists that name Q5170 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Shield of California Promise Health Plan, Cigna, HealthSpring, Molina Healthcare of Illinois, Passport by Molina Healthcare (Kentucky).
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth required | site of care: site-of-service review | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth required | site of care: site-of-service review | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | site of care: site-of-service review | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Teamsters group (TYW) | AZ | prior auth required | Sep 1, 2026 | Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026) | |
| Blue Shield of California Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | Sep 1, 2026 | Medi-Cal Prior Authorization List | |
| Aetna | Medicare Advantage | All | prior auth required | Step therapy applies | Aug 25, 2026 | Aetna Medicare Part B drug list (partbname.xml) |
| Aetna | Commercial | All | prior auth required | Apr 1, 2026 | Participating provider precertification list for Aetna® | |
| Aetna | Medicare Advantage | All | prior auth required | Apr 1, 2026 | Participating provider precertification list for Aetna® | |
| Cigna | ACA/IFP | All | prior auth required | Jul 1, 2026 | Master Precertification List (For Health Care Providers) | |
| Cigna | Basic Standard | All | prior auth required | Jul 1, 2026 | Master Precertification List (For Health Care Providers) | |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | Jul 1, 2026 | Master Precertification List (For Health Care Providers) | |
| HealthSpring | Medicare Advantage | All | prior auth required | Aug 1, 2026 | 2026 Q4 Prior Authorization List | |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | Jul 1, 2026 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
Q5170 appears in 9 coverage policies from Aetna, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare, Wellmark Blue Cross Blue Shield.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Dexamethasone Ophthalmic Implant (Ozurdex) and Insert (Dextenza) (0795) | listed, no stance | Oct 5, 2026 | payer document |
| Aetna | Revakinagene Taroretcel-lwey (Encelto) (1079) | listed, no stance | Oct 5, 2026 | payer document |
| Aetna | Transpupillary Thermal Therapy (0490) | listed, no stance | Oct 5, 2026 | payer document |
| Aetna | Vascular Endothelial Growth Factor Inhibitors for Ocular Indications (0701) | covered if criteria are met | Oct 5, 2026 | payer document |
| Centene | Aflibercept (Eylea, Eylea HD), Aflibercept-mrbb (Ahzantive), Aflibercept-abzv (Enzeevu), Aflibercept-boav (Eydenzelt), Aflibercept-yszy (Opuviz), Aflibercept-ayyh (Pavblu), Aflibercept-jbvf (Yesafili) (CP.PHAR.184) | covered if criteria are met | Feb 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Aflibercept and Associated Biosimilar(s) (OTH903.027) HCPCS Codes J0177, J0178, J3590, Q5147, Q5149, Q5150, Q5153, Q5155 [Deleted | listed, no stance | Jan 1, 2026 | payer document |
| Premera Blue Cross | (effective January 1, 2027) Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders (5.01.620) Page | 7 of 20 | ∞ | listed, no stance | Sep 8, 2026 | payer document |
| UnitedHealthcare | Ophthalmologic Vascular Endothelial Growth Factor (VEGF) Inhibitors (2026D0042AQ) | listed, no stance | Jul 1, 2026 | payer document |
| Wellmark Blue Cross Blue Shield | Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ophthalmic Use (09.03.12) | listed, no stance | Oct 1, 2025 | payer document |
Prior authorization required or conditional in MS.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.