Approved for: office administration (sterile environment/aseptic technique)
Indications for Prior Authorization
- neovascular (WET) age related Macular Degeneration (AMD)
- macular edema secondary to retinal vein occlusion (RVO)
- diabetic macular edema (DME)
The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee.
- combination therapy with verteporfin (Visudyne®)
- any other diagnosis not listed in the approved indications
The dose of ranibizumab for AMD and RVO is not to exceed 0.5 mg (five units) once a month (28 days) by intravitreous injection. The dose for DME is 0.3 mg once a month (28 days).
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: Jan. 2013 Reviewed: December 2013