CurrentCareSourcePolicy N/A

Ozurdex (dexamethasone 0.7 mg intravitreal implant) — Coverage Criteria

Defines prior authorization and medical necessity criteria for coverage of Ozurdex (dexamethasone 0.7 mg intravitreal implant) for retinal vein occlusion (RVO), non-infectious posterior uveitis, and diabetic macular edema (DME) for affected members and ordering providers.

Policy Summary

PayerCareSource

PolicyOzurdex (dexamethasone 0.7 mg intravitreal implant) — Coverage Criteria

Policy CodePolicy N/A

Change TypeAdministrative record of creation and revisions

Effective Date10/01/2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of diagnosis and required clinical records; approvals depend on indication-specific criteria and interval limits.

SourceLink

POLICY UPDATE CHANGES

New policy created for Ozurdex with action date 11/03/2021 and subsequent action/ revision dates listed (10/23/2023, 07/16/2024, 04/09/2025).

0.7 mgimplant dose

1 implant/eyedosage allowed

Indication-specificinterval limits

Prior authauthorization

2025-10-01effective

Policy Summary

PayerCareSource

PolicyOzurdex (dexamethasone 0.7 mg intravitreal implant) — Coverage Criteria

Policy CodePolicy N/A

Change TypeAdministrative record of creation and revisions

Effective Date10/01/2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of diagnosis and required clinical records; approvals depend on indication-specific criteria and interval limits.

SourceLink

On This Page

Coverage Criteria for Ozurdex (dexamethasone 0.7 mg intravitreal implant)

RVO — Initial Authorization (BRVO/CRVO)

Covered when ALL of the following are met:

RVO initial criteria: 1) Medication prescribed by or in consultation with an ophthalmologist; 2) Member is at least 18 years of age; 3) Documented diagnosis of macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO); 4) Trial and failure of or contraindication to an anti-VEGF drug; 5) Member does NOT have active or suspected ocular or periocular infection, torn/ruptured posterior lens capsule, or glaucoma with cup-to-disc ratio > 0.8; 6) Dosage: one implant (0.7 mg) per eye; limit: 2 implants (1 per eye) per 4 months. If met, approval for 3 months.age >=18

RVO — Reauthorization

Reauthorization covered when ALL of the following are met:

RVO reauthorization: 1) At least 4 months have elapsed since the prior treatment of the same eye; 2) Chart notes document improved or stabilized visual acuity. If met, the medication will be approved for an additional 12 months.>=4 months interval

Non-infectious Posterior Uveitis — Initial Authorization

Covered when ALL of the following are met:

Uveitis initial criteria: 1) Member is at least 18 years of age; 2) Medication prescribed by or in consultation with an ophthalmologist; 3) Documented diagnosis of non-infectious uveitis affecting the posterior segment; 4) Trial and failure of at least one systemic corticosteroid (e.g., prednisone) AND one non-biologic immunosuppressive agent (e.g., mycophenolate mofetil, methotrexate, cyclosporine, tacrolimus) each for at least 3 months; 5) Member does NOT have active or suspected ocular or periocular infection, torn/ruptured posterior lens capsule, or glaucoma with cup-to-disc ratio > 0.8; 6) Dosage: one implant (0.7 mg) per eye; limit: 2 implants (1 per eye) per 6 months. If met, approval for 3 months.age >=18

Non-infectious Posterior Uveitis — Reauthorization

Reauthorization covered when ALL of the following are met:

Uveitis reauthorization: 1) At least 6 months have elapsed since the prior treatment of the same eye; 2) Chart notes show improved or stabilized visual acuity and/or improved vitreous haze score; 3) Member has recurrent symptoms. If met, the medication will be approved for an additional 12 months.>=6 months interval

Diabetic Macular Edema (DME) — Initial Authorization

Covered when ALL of the following are met:

DME initial criteria: 1) Member is at least 18 years of age; 2) Medication prescribed by or in consultation with an ophthalmologist; 3) Documented diagnosis of diabetic macular edema; 4) Member does NOT have active or suspected ocular or periocular infection, torn/ruptured posterior lens capsule, or glaucoma with cup-to-disc ratio > 0.8; 5) Dosage: one implant (0.7 mg) per eye; limit: 2 implants (1 per eye) per 3 months. If met, approval for 3 months.age >=18

Diabetic Macular Edema (DME) — Reauthorization

Reauthorization covered when ALL of the following are met:

DME reauthorization: 1) At least 3 months have elapsed since the prior treatment of the same eye; 2) Chart notes show improved or stabilized visual acuity following treatment. If met, the medication will be approved for an additional 12 months.>=3 months interval

CareSource considers Ozurdex (dexamethasone 0.7 mg intravitreal implant) not medically necessary for any indication not expressly listed in this policy. Requests for use of Ozurdex for off‑label or other unlisted conditions will be evaluated under the plan's Off‑Label policy and are not covered by this document.

Treatment with Ozurdex for conditions other than those specified in this policy (for example, any indication not enumerated under the covered clinical scenarios) is not medically necessary and will be denied unless coverage is supported under the Off‑Label policy.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Ozurdex (dexamethasone intravitreal implant). Initial and reauthorization criteria vary by indication (RVO, non-infectious posterior uveitis, and diabetic macular edema) and must be met for approval. Requests that do not meet the specific indication criteria, contraindications, or required documentation will be denied.

Applies to Ozurdex (dexamethasone 0.7 mg intravitreal implant)
Coverage is medical benefit and requires prior authorization

Step Therapy

Step Therapy Requirements

Step therapy requirements differ by indication. For macular edema due to retinal vein occlusion (BRVO/CRVO), there must be trial and failure of, or contraindication to, an anti-VEGF agent prior to approval of Ozurdex. For non-infectious posterior uveitis, members must have tried and failed at least one systemic therapy (e.g., systemic corticosteroid and/or a non-biologic immunosuppressive agent) for at least 3 months prior to Ozurdex unless contraindicated.

Background and Policy Context

Ozurdex is an intravitreal implant containing 0.7 mg dexamethasone used to treat certain posterior segment eye diseases. This policy addresses use of the implant for macular edema due to retinal vein occlusion (RVO), non‑infectious posterior segment uveitis, and diabetic macular edema (DME). Prior authorization is required and reauthorization criteria include documentation such as elapsed minimum intervals since prior treatment and clinical response (for example, improved or stabilized visual acuity).

Definitions and Key Terms

Ozurdex (dexamethasone) — definition

Generic name & formulationOzurdex — intravitreal implant containing dexamethasone 0.7 mg

Indications (listed in policy)Macular edema due to retinal vein occlusion (RVO), posterior segment (non-infectious) uveitis, and diabetic macular edema (DME)

Benefit & authorization statusMedical benefit; prior authorization required

Typical dose per implant0.7 mg dexamethasone per implant

Administration siteIntravitreal (implant inserted into the vitreous of the eye)

Diabetic Macular Edema (DME) — definition

RVO (BRVO/CRVO): Trial and failure of or contraindication to an anti-VEGF drug required
Non-infectious posterior uveitis: Failure of at least one systemic corticosteroid and/or a non-biologic immunosuppressive (e.g., mycophenolate, methotrexate, cyclosporine, tacrolimus) for ≥3 months required

Documentation Required

Required Clinical Documentation

Required clinical documentation must be provided with requests. Chart notes should document baseline diagnosis, prior treatments, contraindications or reasons for step-therapy exemption, and post-treatment response. For continuation/reauthorization, chart notes must document improved or stabilized visual acuity after treatment; for non-infectious posterior uveitis, documentation may also require improved vitreous haze score and evidence of recurrent symptoms as specified.

Initial and reauthorization requests: Ophthalmologist involvement (prescribed by or in consultation with an ophthalmologist) documented
Reauthorization: Chart notes documenting improved or stabilized visual acuity following treatment
Uveitis reauthorization: Chart notes documenting improved/stabilized visual acuity and/or improved vitreous haze score and recurrent symptoms

Denial Risk

Off-Label Indications Not Covered

Use of Ozurdex for indications not listed in this policy (off-label uses) is considered not medically necessary and will be denied. Refer to the payer's Off-Label policy for exceptions.

Off-label indications are not covered under this policy

Billing Rule

Quantity / Frequency Limits

Quantity and frequency limits apply and requests exceeding these limits or shorter-than-allowed intervals may be denied. Limits vary by indication as follows:

Retinal Vein Occlusion (BRVO/CRVO) – Dosage/quantity: One implant (0.7 mg) per eye. Limit: up to 2 implants (maximum 1 per eye) per 4 months. Reauthorization: at least 4 months must have elapsed since prior treatment to the same eye.
Diabetic Macular Edema (DME) – Dosage/quantity: One implant (0.7 mg) per eye. Limit: up to 2 implants (maximum 1 per eye) per 3 months. Reauthorization: at least 3 months must have elapsed since prior treatment to the same eye.
Non-infectious Posterior Uveitis – Dosage/quantity: One implant (0.7 mg) per eye. Limit: up to 2 implants (maximum 1 per eye) per 6 months. Reauthorization: at least 6 months must have elapsed since prior treatment to the same eye.

Diabetic macular edema (DME): fluid build-up in the macula due to leakage from retinal capillaries associated with diabetic retinopathy

Clinical consequenceCan result in loss of central vision if untreated

Etiology emphasisAssociated with capillary leakage; importance of glucose control noted

Relationship to OzurdexDME is one of the listed indications for Ozurdex intravitreal implant