Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Corticosteroid Intravitreal Implants (Ozurdex, Retisert, Yutiq, Dextenza, and Iluvien) require prior authorization.

2)    Retisert is an intravitreal implant for the treatment of non-infectious uveitis affecting the posterior segment of the eye.

3)    Iluvien is indicated for the treatment of diabetic macular edema in patients who have been previously treated with corticosteroids and did not have a clinically significant rise in intraocular pressure.

4)    Ozurdex is indicated for the treatment of a) macular edema following brand retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO), b) non-infectious uveitis affecting the posterior segment of the eye, and c) diabetic macula edema (DME).

5)    Yutiq is an intravitreal implant indicated for the treatment of chronic non-infectious uveitis affecting the posterior segment of the eye.

6)    Dextenza is an ophthalmic insert approved for the treatment of ocular pain following ophthalmic surgery.

7)    Xipere is a suprachoroidal injection indicated for the treatment of macular edema associated with uveitis.

1)    Corticosteroidophthalmic injections (Retisert,Iluvien, Yutiq, Dextenza, Xipere, and Ozurdex) all require prior authorization.

2)    Retisert is considered medically necessary for members meeting the following criteria:

a)    Member is 12 years of age or older AND

b)    Diagnosis of non-infectious uveitis affecting the posterior segment of the eye AND

c)    Prescribed by or in consultation with an ophthalmologist AND

d)    Failure of all of the following unless contraindicated or clinically significant adverse effects are experienced:

i)     Intravitreal steroid injections;

ii)    Systemic corticosteroid;

iii)   Non-biologic immunosuppressive therapy;

e)    Dose does not exceed one (1) implant per eye

3)    Iluvien is considered medically necessary for members meeting the following criteria:

a)    Member is 18 years of age older AND

b)    Diagnosis of Diabetic Macular Edema (DME) AND

c)    Prescribed by or in consultation with an ophthalmologist AND

d)    Failure of:

i)     Intravitreal anti-VEGF agents;

     e) Dose does not exceed one (1) implant per eye.

4) Ozurdex is considered medically necessary for members meeting the following criteria:

Diabetic Macular Edema

a)    Member is 18 years of age or older AND

b)    Diagnosis of diabetic macular edema (DME) AND

c)    Prescribed by or in consultation with an ophthalmologist AND

d)    Failure of both of the following unless contraindicated or clinically significant adverse effects are experienced:

i)     Intravitreal steroid injections;

ii)    Intravitreal ant-VEGF agents

e)    Dose does not exceed one (1) implant per eye

Macular Edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO)

a)    Member is 18 years of age or older AND

b)    Diagnosis of macular edema following BRVO or CRVO AND

c)    Prescribed by or in consultation with an ophthalmologist AND

d)    Failure of both of the following unless contraindicated or clinically significant adverse effects are experienced:

1)    Intravitreal antiVEGF agents;

e)    Dose does not exceed one (1) implant per eye.

5) Yutiq (fluocinolone) is indicated for use in treating non-infectious uveitis.

4)    6) Dextenza (dexamethasone) is used to treat ocular inflammation and pain after ophthalmic surgery.

7) Xipere (triamcinolone acetonide) is considered medically necessary for members who meet the following criteria:

      a) Diagnosis of macular edema associzted with non-infectious uveitis;

      b) Prescribed by or in consultation with an ophthalmologist;

      c) Age > 18 years;

      d) Dose does not exceed 4mg (1 vial) per eye every 12 weeks.

Codes Used In This BI:

J7311             Fluocinolone acetonide intravitreal implant

J7312             Injection, dexamethasone, intravitreal implant, 0.1mg

J7313             Injection, fluocinolone acetonide intravitreal implant, 0.01mg

C9048            Dexamethasone, lacrimal ophthalmic insert, 0.1mg

J7314             Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01mg

J1096             Dexamethasone, lacrimal ophthalmic insert, 0.1mg (Dextenza)

1)    Iluvien Prescribing Information. Alpharetta, GA: Alimiera Sciences, Inc. Novembe 2016.

2)    Ozurdex Prescribing Information. Irvine, CA: Allergan, Inc. September 2014.

3)    Retisert Prescribing Information. Bridgewater, NJ: Valeant Pharmaceuticals; December 2017.

4)    Yutiq Prescribing Information. Watertown, MA. EyePoint Pharmaceuticals US, Inc. October 2018.

5)    Dextenza Prescribing Information. Bedford, MA. Ocular Therapeutix. June 2019.

6)    Xipere Prescribing Information. Alpharetta, GA: Clearside Biomedical, Inc,.; October 2021.

Addendum:

Effective 04/01/2019: Established coverage criteria for Retisert and Iluvien. Included coverage criteria for Ozurdex in this policy as well so as to include all corticosteroid intravitreal implants in same policy.

Effective 10/01/2019: Added Yutiq and Dextenza coverage criteria.

Effective 7/1/2022: Added Xipere coverage criteria.