ILUVIEN (fluocinolone acetonide)
OFFICE ADMINISTRATION / OUTPATIENT FACILITY INFUSION ADMINISTRATION ONLY
Indications for Prior Authorization:
- Diabetic macular edema
All of the following must be met as a condition for coverage (must include chart note documentation as supporting information):
- Diagnosis of diabetic macular edema in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure
This Medication is Not Approvable for the following condition(s):
- Any condition not listed above as an approved indication
- Safety and efficacy in pediatric patients have not been established
Dosing:
- One implant (0.19 mg) in the affected eye by intravitreal injection. The implant is designed to release fluocinolone at an initial rate of 0.25mcg/day lasting 36 months
Approval:
36 months (3 years)
Last review date: September 6, 2016