Fluocinolone acetonide intravitreal implant (Iluvien®)

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

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