Eylea Prior Authorization, Part II: The Real Cost

Executive Summary

A retina or ophthalmology practice running 40 Eylea prior authorization requests per month (not an unusual volume for a mid-sized injection practice) is generating roughly 67 hours of PA-related staff time every month. That is approximately 800 hours per year, or 0.38 FTE: more than one third of a full-time billing position consumed by a single drug's authorization workflow. For practices running 80 authorizations per month, that figure reaches 0.77 FTE at the median and crosses 1.0 FTE when payer mix skews toward step therapy-intensive plans.

These are not estimates assembled from general industry data. They are derived from a prospective multicenter study published in JAMA Ophthalmology (Dang et al., 2024) that tracked 2,225 anti-VEGF prior authorization requests across nine US retina practices, logging staff time for each request and finding a median of 100 minutes per PA, with a range of 0 to 200 minutes. The goal of this piece is to convert that finding into practice-level math, broken down by task, modeled across a realistic range of volumes and hourly costs, and connected to what changes when the workflow is automated.

Where Part I Left Off:

An earlier piece by Conor covered why the Eylea PA workflow is so administratively punishing: the step therapy trap that forces practices to document bevacizumab trial before Eylea is approved, the added complexity of Eylea HD and biosimilar policies, and the fact that 60% of approvals still result in care delays even when the authorization ultimately succeeds. That piece made the qualitative case. Let’s now quantify it.

Eylea prior authorization sits at the intersection of everything that makes specialty PA difficult. The drug is clinically essential for patients with wet AMD, diabetic macular edema, and related retinal conditions. It is also high-cost, which makes it a target for payer cost controls: step therapy requirements, documentation-intensive submission standards, and authorization policies that vary by plan tier and change without consistent notice.

The JAMA Ophthalmology study that this piece is built on changes what that quantification looks like. One hundred minutes per PA request is the median. The range is 0 to 200 minutes. Across 2,225 requests at nine practices, the cumulative total was 1,742 staff hours. The question this piece answers is what those numbers mean for a practice at a specific injection volume, converted to hours per month, FTE equivalents, and annual staff cost, and where in the 100-minute workflow the time is actually going.

The Source Data: What the JAMA Ophthalmology Study Found

The quantitative foundation for this piece is a prospective multicenter quality improvement study published in JAMA Ophthalmology in June 2024 (Dang S, Parke W, Sodhi GS, et al.). The study tracked prior authorization requests for anti-VEGF medications (aflibercept (Eylea), ranibizumab (Lucentis), and bevacizumab (Avastin)) across nine private retina practices in six US states from January through June 2022.

The study logged 2,365 PA requests, of which 2,225 met the inclusion criteria. Of those, 96.2% were eventually approved. The dataset recorded staff time for each request, producing the 100-minute median and 0-to-200-minute range that have become the most-cited figures in the ophthalmology PA burden literature.

Several aspects of the dataset are worth understanding before applying the numbers.

The 100-minute figure represents the median, not the mean. The distribution has a meaningful right tail driven by step therapy cases, pend and resubmission cycles, and documentation rework. Practices with higher step therapy exposure will see their per-request average skew above the median.

The 100-minute figure captures PA preparation, submission, and same-session follow-up as logged by practice staff. The study explicitly excluded time spent on appeals, peer-to-peer review coordination, and the clinical scheduling disruption caused by the 59.6% of approved cases that still resulted in care delays. Those are real costs that sit outside the median and are addressed separately below.

Sixty-four percent of the requests were reauthorizations for a previously approved medication. New authorizations and medication changes carry higher documentation requirements and denial risk and represent a smaller share of volume but a disproportionate share of above-median time cases.

Breaking Down the 100 Minutes

The 100-minute median is a composite of distinct workflow tasks, each with a different time profile and a different susceptibility to automation. The table below maps the components, with typical time ranges and the primary drivers of variance within each.

The rework loop and appeals rows are outside the JAMA median and are treated as add-on load below. The base 100-minute figure reflects the median case: a standard authorization request that moves through initiation, documentation, submission, and same-session resolution without a pend or denial.

The Step Therapy Multiplier

Step therapy is the workflow variable most likely to push a given Eylea authorization from the median toward the upper end of the observed range, and it is worth examining operationally rather than just statistically.

The JAMA Ophthalmology study found that step therapy accounted for 76% of the reasons for non-approval in the 3.8% of cases where initial authorization was not granted. But the staff time impact of step therapy is not limited to denied cases. It applies to any case where step therapy documentation must be assembled as part of the initial submission, including proof of bevacizumab trial, evidence of inadequate response, and clinical rationale for the current drug choice, whether or not the payer ultimately approves on first submission.

The detailed patterns behind these documentation failures, and how they produce predictable denial categories across ophthalmology practices, are examined in decoding the denial.

A step therapy case, as it unfolds:

A patient with wet AMD has been receiving anti-VEGF injections for two years. The practice is submitting a reauthorization for Eylea under a Medicare Advantage plan that requires documented bevacizumab trial before approving aflibercept. The patient trialed bevacizumab 18 months ago, responded inadequately, and transitioned to Eylea, but the bevacizumab encounter is in a prior chart section that requires separate navigation.

A billing coordinator spends 15 minutes locating the encounter, 10 minutes extracting the specific injection dates and dosing, and 10 minutes finding the OCT progression note that documents the inadequate response. Another 10 minutes goes to obtaining the physician's written rationale for the current drug selection, formatted to the payer's documentation standard. The submission goes out. Two days later, a pend response arrives requesting additional clinical context. The coordinator spends 20 minutes preparing the supplemental documentation and resubmitting. The authorization is approved on second submission.

Total time for this case: approximately 160 minutes, well above the median and consistent with the upper range documented in the JAMA study. The treatment was always going to be approved. The staff time was a function of payer policy requirements and documentation variability, not clinical complexity.

Converting Minutes to FTE Cost: The Practice-Level Math

The 100-minute median becomes meaningful for practice management when converted from a per-request figure to an FTE and annual cost model. The critical inputs are injection volume, a plausible time-per-request assumption, and fully loaded hourly cost. The table below shows how those inputs interact across a realistic range.

Notes on the inputs:

Monthly PA volume reflects Eylea and anti-VEGF authorizations specifically, not total practice PA volume. The 70/100/130 minutes-per-PA range uses the JAMA study median of 100 as the central case, with 70 representing a lower-complexity practice mix (higher share of routine reauthorizations, fewer step therapy cases) and 130 representing a higher-complexity mix (more new authorizations, more step therapy documentation requirements). Fully loaded hourly rates of $28, $36, and $45 reflect a regional range for billing coordinator roles including employer payroll taxes and benefits at a standard 25% load factor above base salary.

The FTE framing is the figure that matters most for practice management. A practice running 80 Eylea authorizations per month at the median time is carrying 0.77 FTE in PA administration. At the upper end of the time range, that same volume reaches 1.00 FTE: a full-time position whose entire output is Eylea authorization work.

The add-on load outside the JAMA median:

The figures above cover the base PA workflow. For pended requests, the rework loop adds 20 to 60 minutes per case depending on what the pend requires. For cases that proceed to appeal or peer-to-peer review, the time sits outside the study's logging and should be tracked separately. A practice where 15% of requests receive a pend or denial response, a reasonable operational scenario for a step therapy-heavy payer mix, adds approximately 10% to 15% to the annual hours total, depending on how those cases resolve.

What a Broader Survey Confirms

The JAMA Ophthalmology study is specific to anti-VEGF authorizations in retina practices. To understand where that burden sits relative to a practice's total authorization workload, the AMA's 2024 Prior Authorization Physician Survey offers a useful frame of reference.

The AMA conducts this survey annually across 1,000 practicing physicians representing both primary care and specialty settings. The 2024 edition found that practices complete an average of 39 prior authorization requests per physician per week, with physicians and their staff spending approximately 13 hours on those requests each week. Forty percent of physician practices reported having staff who work exclusively on prior authorizations.

For a retina or ophthalmology practice with significant Eylea volume, anti-VEGF PAs likely represent the largest single category within that 39-per-week average. The 13 hours per week figure, roughly 1.5 full business days, aligns closely with the math that emerges from applying the JAMA median to a practice running meaningful injection volume.

What the AMA data adds is scale. The administrative burden documented in the JAMA Ophthalmology study is not unique to retina practices. It is a consistent finding across specialties, confirmed by the largest annual physician survey in the US, and it reflects a structural cost that the industry has largely treated as fixed overhead rather than as an addressable operational problem.

Why the Eylea Environment Is Getting Harder, Not Easier

The JAMA Ophthalmology data was collected in 2022. The payer environment that practices navigate today is meaningfully more complex, and the trend is not toward simplification.

Step therapy protocols for Eylea and Eylea HD have expanded across major payers in 2025. UnitedHealthcare, Aetna, and Humana have each tightened their Medicare Advantage PA policies for anti-VEGF agents. Aetna's Medicare Advantage formulary classifies both Eylea and Eylea HD as non-preferred drugs, favoring bevacizumab and biosimilars in most clinical scenarios. UnitedHealthcare enforces prior authorization across both commercial and Medicare Advantage lines of business and requires documented Avastin trial before Eylea approval unless contraindicated.

The introduction of biosimilars has added a further layer of policy variability. Pavblu (aflibercept-mrbb), the first aflibercept biosimilar, entered the market in 2024 and is now appearing on payer preferred drug lists as an alternative to brand Eylea. Practices are navigating PA policies that distinguish between Eylea, Eylea HD, and Pavblu, with different coverage criteria, step therapy requirements, and documentation standards for each, in an environment where those policies change faster than any manual tracking process can reliably follow.

KFF data published in 2025 found that Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024. For ophthalmology practices with a Medicare Advantage-heavy payer mix, authorization volume is not decreasing. The regulatory infrastructure being built under CMS-0057-F and the 2027 prior authorization rule will eventually improve how authorizations are transmitted. The payer-side policy complexity that determines how long each one takes will not resolve through infrastructure alone.

What Changes When the Workflow Is Automated

The staff time figures in this piece are not arguments for resignation. They are arguments for precision. A cost that can be measured can be addressed, and the components of the Eylea PA workflow that drive the most time are the components most directly addressable through automation.

It is worth being clear about what kind of problem this is. Eylea PA time is not simply clerical work that needs to be done faster. It is work created by unknown requirements and variable payer rules, the time consumed by staff figuring out what a specific payer needs for a specific patient under a specific plan tier, then assembling evidence that satisfies those requirements, then following up when the payer requests more. That is an intelligence problem, not a throughput problem, and it is why adding staff to handle PA volume tends to scale cost linearly while doing little to address the per-request time.

Coverage Intelligence addresses the intelligence layer directly. PA requirement determination, including whether Eylea requires authorization under a specific payer and plan tier and whether step therapy documentation is required for this patient, is automated against real-time payer policy data, eliminating manual lookup and the error risk from outdated knowledge. Documentation assembly draws from structured EHR data and maps it to payer requirements, compressing the 20-to-30-minute documentation task. Status monitoring replaces manual phone-based follow-up for pended requests.

Rocky Mountain Eye Center, an ophthalmology practice that implemented Manta's Coverage Intelligence platform, reduced prior authorization approval time by 75%, from 11-12 days to 2.8 days, and achieved a 1.9% initial denial rate with a 0.5% net denial rate after appeals. The operational result that maps most directly to this piece's cost model: the practice reduced its PA specialist headcount from five to one. Applied to the sensitivity table in this piece, that is four FTE positions recovered, with staff capacity shifted from authorization administration to patient-facing work.

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