CurrentColorado Rocky Mountain Health PlansPolicy 2025D0138B

Susvimo® (Ranibizumab Injection) – Commercial Medical Benefit Drug Policy

Defines medical necessity criteria, continuation criteria, and applicable procedure/diagnosis codes for Susvimo (ranibizumab intravitreal implant J2779) under the commercial medical benefit.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySusvimo® (Ranibizumab Injection) – Commercial Medical Benefit Drug Policy

Policy CodePolicy 2025D0138B

Change TypeRevised diagnoses list; references updated

Effective DateSep 1, 2025

Next Review Date

Key ActionInitial authorization limited to no longer than 12 months and requires documentation that the patient previously responded to at least two intravitreal VEGF inhibitor injections and has one of the specified diagnoses; dosing must follow FDA labeling.

SourceLink

POLICY UPDATE CHANGES

Revised list of applicable diagnoses for which Susvimo is proven and medically necessary; added diabetic retinopathy (DR).

Updated Clinical Evidence, FDA, and References sections to reflect the most current information.

3Covered Indications (diagnoses listed)

1Drug HCPCS code listed

2Authorization types