CurrentCentenePolicy CP.PHAR.536

Ophthalmic Riboflavin (Photrexa, Photrexa Viscous)

Defines medical necessity criteria, initial and continuation approval, dosing/administration notes, excluded indications, and coding implications for Photrexa and Photrexa Viscous used as photoenhancers for corneal collagen cross-linking in combination with the KXL System across Commercial, ICHRA/Marketplace, and Medicaid lines of business.

Policy Summary

PayerCentene

PolicyOphthalmic Riboflavin (Photrexa, Photrexa Viscous)

Policy CodePolicy CP.PHAR.536

Change TypeAnnual reviewnon‑material updates

Effective Date06.01.21

Next Review Date

Key ActionProvider must submit documentation (office chart notes, lab results or other clinical information) supporting that member has met all approval criteria.

SourceLink

POLICY UPDATE CHANGES

Added ICHRA line of business during 2Q 2026 annual review; references reviewed and updated.

Updated HCPCS code description for J2787 during 2Q 2024 annual review.

2FDA-Approved Indications

14Minimum Age (years)

1Kits allowed per eye

400 micronsMinimum corneal thickness

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Policy CP.PHAR.536 (Clinical Policy: Ophthalmic Riboflavin) addresses Photrexa and Photrexa Viscous, topical ophthalmic riboflavin photoenhancers used with the KXL System for corneal collagen cross-linking. The FDA-approved indications are for progressive keratoconus and corneal ectasia following refractive surgery. This policy applies to the Commercial, ICHRA/Marketplace (listed as HIM/ICHRA), and Medicaid lines of business and the overall coverage stance is covered_with_criteria. The policy defines medical necessity criteria for initial and continued therapy, documentation requirements, dosing/administration notes, excluded indications, and coding implications.

Quick facts — policy thresholds

FDA-Approved Indications2

Minimum Age14 years

Kits allowed per eye1

Minimum corneal thickness for irradiation≥ 400 microns

Time since prior procedure for continuation≥ 6 months

Initial Therapy Criteria

I. Initial Approval Criteria

Approval of the drug does not translate to an approval of the corneal cross-linking procedure. Photrexa and Photrexa Viscous are medically necessary when ALL of the following are met:

ALL of the following

Diagnosis of one of the following
- Progressive keratoconus
- Corneal ectasia following refractive surgery
Prescribed by or in consultation with an ophthalmologist
Age ≥ 14 years≥ 14 years
Patient must be at least 14 years old
Dose does not exceed one kit per eye≤ one kit per eye
Maximum one kit per eye

I.B. Other diagnoses/indications

If the request is for other diagnoses/indications (must meet ONE of the following):

ANY of the following

If this drug has recently (within the last 6 months) undergone a label change that is not yet reflected in this policy, follow the relevant no-coverage or non-formulary policy for the line of business
Refer to CP.CPA.190 (commercial), HIM.PA.33 or HIM.PA.103 (marketplace/ICHRA), CP.PMN.255 or CP.PMN.16 (Medicaid) depending on formulary status
If requested use is not listed under section III and criterion 1 does not apply, refer to the off-label use policy for the relevant line of business
Refer to CP.CPA.09 (commercial), HIM.PA.154 (marketplace/ICHRA), CP.PMN.53 (Medicaid)

Continuation Therapy Criteria

II. Continued Therapy

Approval of the drug does not translate to an approval of the corneal cross-linking procedure. Continued therapy for Progressive Keratoconus and Corneal Ectasia is medically necessary when ALL of the following are met:

ALL of the following

Member meets one of the following
- Currently receiving medication via Centene benefit or member has previously met initial approval criteria
- Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations
  Refer to state specific addendums CC.PHARM.03A and CC.PHARM.03B
At least 6 months have passed since member's last collagen cross-linking procedure≥ 6 months
Member is responding positively to therapy as evidenced by a reduction in diopters in the treated eye(s)
If request is for a dose increase, new dose does not exceed one kit per eye≤ one kit per eye
Maximum one kit per eye

II.B. Continued Therapy - Other diagnoses/indications

If the request is for other diagnoses/indications (must meet ONE of the following):

ANY of the following

If drug label changed within last 6 months not yet reflected, follow relevant no-coverage or non-formulary policy
Refer to CP.CPA.190, HIM.PA.33/.103, CP.PMN.255/.16 as appropriate
If requested use not listed under section III and criterion 1 above does not apply, refer to off-label use policy for relevant line of business
Refer to CP.CPA.09, HIM.PA.154, CP.PMN.53

Diagnoses / Indications Not Authorized

III. Diagnoses/Indications Not Authorized

Non-FDA approved indications which are not addressed in this policy are not authorized unless there is sufficient documentation of efficacy and safety per off-label use policies or evidence of coverage documents

Refer to CP.CPA.09 (commercial), HIM.PA.154 (marketplace/ICHRA), CP.PMN.53 (Medicaid)

Provider Actions & Authorization Requirements

Prior Authorization

Prior authorization requirement and approval duration

Approval is for up to 6 months and up to one kit per eye. Providers should request prior authorization per the plan's procedures and supply required documentation when submitting the request.

Documentation Required

Support for medical necessity

Provider must submit documentation (such as office chart notes, lab results, or other clinical information) supporting that the member has met all approval criteria.

Documentation Required

Evidence of positive response for continuation

For continued therapy, documentation must demonstrate a positive response to treatment; specifically, records must show a reduction in diopters in the treated eye(s).

Documentation Required

Prescribing clinician

The medication must be prescribed by or in consultation with an ophthalmologist.

Billing Rule

Coding reference

HCPCS code J2787 is provided for informational purposes; inclusion of the code does not guarantee coverage. Providers should reference the most current professional coding guidance prior to claim submission.

Clinical Evidence & References

Reference: Photrexa Viscous and Photrexa Prescribing Information, Avedro; February 2025 (label link updated Feb 11, 2026). The Prescribing Information is the source for the dosing regimen and clinical prerequisites referenced in this policy, including the dosing/administration steps for epithelial debridement and instillation schedules, the requirement to observe a yellow anterior chamber flare, and the corneal thickness threshold of ≥ 400 microns prior to irradiation. The Prescribing Information should be consulted for full, exact dosing instructions and clinical decision points.

Clinical thresholds (prescribing information)

Minimum corneal thickness for irradiation≥ 400 microns

Kits allowed per eye1

Minimum age≥ 14 years

Background

Photrexa and Photrexa Viscous are topical ophthalmic riboflavin photoenhancers indicated, in combination with the KXL System, for corneal collagen cross-linking to treat progressive keratoconus and corneal ectasia following refractive surgery. This policy and indications apply to the Commercial, ICHRA/Marketplace, and Medicaid lines of business.

FDA: Food and Drug Administration

Policy Summary

PayerCentene

PolicyOphthalmic Riboflavin (Photrexa, Photrexa Viscous)

Policy CodePolicy CP.PHAR.536

Change TypeAnnual reviewnon‑material updates

Effective Date06.01.21

Next Review Date

Key ActionProvider must submit documentation (office chart notes, lab results or other clinical information) supporting that member has met all approval criteria.

SourceLink

On This Page

OpenPayer

Ophthalmic Riboflavin (Photrexa, Photrexa Viscous)

Coverage Summary & Scope

Initial Therapy Criteria

Continuation Therapy Criteria

Diagnoses / Indications Not Authorized

Provider Actions & Authorization Requirements

Applicable Codes

Clinical Evidence & References

Background

Revision History