Pharmacy Prior Authorization Criteria

Encelto (revakinagene taroretcel-lwey)

Indications for Prior Authorization

Encelto (revakinagene taroretcel-lwey)

• For diagnosis of Macular telangiectasia type 2 (MacTel)
  Indicated for the treatment of adults with idiopathic macular telangiectasia type 2 (MacTel).

Criteria

Encelto

Prior Authorization

Length of Approval: 1 Time Authorization per Eye in Lifetime

• Diagnosis of macular telangiectasia type 2 (MacTel)
AND
• Ellipsoid Zone (EZ) loss as measured by optical coherence tomography (OCT) from .16mm^2 and 2.00mm^2."
AND
• Patient does not have neovascular macular telangiectasia (Mac Tel)
AND
• Patient’s best corrected visual acuity (BCVA) is 20/80 or better
AND
• Provider attests patient has not received prior treatment with Encelto in the affected eye in their lifetime
AND
• Prescribed by or in consultation with an ophthalmologist experienced in the treatment of retinal diseases

P & T Revisions

1970-01-01

References

1. Encelto Prescribing information. Neurotech Pharmaceuticals, Inc. Cumberland, RI. March 2025.
2. ClinicalTrials.gov. A Study to Determine the Safety and Efficacy of NT-501 in Macular Telangiectasia Type 2 - Protocol A. Available at: https://www.clinicaltrials.gov/study/NCT03316300?cond=NCT03316300&rank=1#participation-criteria. Accessed June 13, 2025.
3. ClinicalTrials.gov. A Study to Determine the Safety and Efficacy of NT-501 in Macular Telangiectasia Type 2 - Protocol B. Available at: https://www.clinicaltrials.gov/study/NCT03319849?cond=NCT03319849&rank=1#participation-criteria. Accessed June 13, 2025.

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Revision History

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