aflibercept (Eylea)

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