Visudyne (verteporfin) Pharmacy Policy Statement
Defines prior authorization criteria, dosing/quantity limits, initial and reauthorization clinical requirements, and coverage exclusions for Visudyne (verteporfin) when used for photodynamic therapy to treat choroidal neovascularization (CNV). Applies to medical benefit (Visudyne = Medical) under Arkansas PASSE benefit.
Policy created 10/19/2021
Revised 10/04/2023 to add references
Coverage Summary
Coverage stance: covered_with_criteria for Visudyne (verteporfin) photodynamic therapy for choroidal neovascularization (CNV). Effective date: 2024-04-01. Scope: defines prior authorization criteria, dosing/quantity limits, initial and reauthorization clinical requirements, and coverage exclusions for Visudyne when used for PDT to treat CNV; applies to the medical benefit (Visudyne = Medical) under the Arkansas PASSE benefit. Approval duration/quantity: 1 dose per eye per 3 months for initial approval (and for each reauthorization when criteria met). Dose per administration: 6 mg/m2 body surface area IV.
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