| 463 | For the treatment of patients with neovascular (wet) age-related macular degeneration (AMD) in a verteporfin PDT (Visudyne)-naive eye.
Initial diagnosis should be confirmed by an appropriate diagnostic procedure and administration should be done by a qualified ophthalmologist experienced in intravitreal injections.
Patients receiving concurrent administration of verteporfin PDT (Visudyne) or ranibizumab (Lucentis) are not eligible for reimbursement.
Treatment should be initiated with a monthly intravitreal injection for the first 3 consecutive doses, followed by one injection every 2 months.
The interval between two doses should not be shorter than one month.
Treatment with anti-VEGF agents should only be continued in patients who maintain adequate response to therapy.
For clarity, coverage will be provided for patients responding to therapy with Lucentis who switch to Eylea. Coverage will NOT be provided for patients who have failed to respond to Lucentis. |
| | LU Authorization Period: 1 year |
| 464 | For the treatment of patients with clinically significant macular edema secondary to branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO).
Treatment should be initiated with an intravitreal injection once every month. The interval between two doses should not be shorter than one month. The treatment interval may be extended up to 3 months based on visual and anatomic outcomes.
Prescribers are advised to periodically assess the need for continued therapy.
Treatment with anti-VEGF agents should only be continued in patients who maintain adequate response to therapy.
For clarity, coverage will be provided for patients responding to therapy with Lucentis who switch to Eylea. Coverage will NOT be provided for patients who have failed to respond to Lucentis. |
| | LU Authorization Period: 1 year |
| 465 | For the treatment of patients with clinically significant diabetic macular edema (DME) for whom laser photocoagulation is also indicated; and a hemoglobin A1c of less than 12 percent.
Treatment should be initiated with a monthly intravitreal injection for the first 5 consecutive doses, followed by one injection every 2 months.
The interval between two doses should not be shorter than one month.
Treatment with anti-VEGF agents should only be continued in patients who maintain adequate response to therapy.
For clarity, coverage will be provided for patients responding to therapy with Lucentis who switch to Eylea. Coverage will NOT be provided for patients who have failed to respond to Lucentis. |
| | LU Authorization Period: 1 year |
