Bevacizumab (intra-ocular)

Approved for: office administration- sterile environment/aseptic technique

Indications for Prior Authorization

  • neovascular (WET) age related Macular Degeneration (AMD)
  • macular retinal edema
  • diabetic macular edema
  • cystoid macular degeneration
  • rubeosis iridis
  • choroidal neovascularization, one or more of the following:
  • angioid streaks
  • choroiditis
  • degenerative myopia
  • retinal dystrophies
  • neovascular glaucoma
  • retinal vein occlusion (branch or central)

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee.

  • any other diagnosis not listed in the approved indications

Dosing

Up to 2.5mg every 4 weeks by intravitreal injection.

Monitoring

elevation in intraocular pressure ocular inflammation (endophthalmitis) immediately after injection check for perfusion of the optic nerve head measure intraocular pressure (tonometry) within 30 minutes following injection slit lamp biomicroscopy between 2 and 7 days following injection


Western Health Advantage Pharmacy and Therapeutics Committee

Approved/Revised: Sep. 2012 Reviewed: December 2013