EYLEA (aflibercept)
OFFICE ADMINISTRATION
Indications for Prior Authorization:
- Diabetic macular edema (DME)
- Macular edema (ME) due to central retinal vein occlusion
- Neovascular (WET) age-related macular degeneration (AMD)
This Medication is NOT Covered for:
- Conditions not listed in this policy
Dosing:
Diabetic macular edema
- 2 mg (0.05 ml) intravitreal every 4 weeks for 5 months, then 2 mg intravitreal every other month.
Macular edema (ME) due to central retinal vein occlusion
- 2 mg (0.05 ml) intravitreal injection every month
Neovascular (WET) age-related macular degeneration
- 2 mg (0.05 ml) intravitreal injection every month for 3 months, followed by every other month
Approval Period:
Yearly
Last review date: July 20, 2016