Premera Bluecross intravitreal corticosteroids Coverage Update | OpenPayer

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Premera Bluecross intravitreal corticosteroids Coverage Update | OpenPayer

Medical Necessity Criteria (grouped by product / indication)

Ozurdex (dexamethasone intravitreal implant) — Macular edema following BRVO or CRVO

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- ALL of the following
  - Active or suspected ocular or periocular infection
  - Glaucoma with a cup to disc ratio of greater than 0.8
  - Torn or ruptured posterior lens capsule
- Individual is aged 18 years and older

Ozurdex — Non-infectious uveitis of the posterior segment

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- ALL of the following
  - Active or suspected ocular or periocular infection
  - Glaucoma with a cup to disc ratio of greater than 0.8
  - Torn or ruptured posterior lens capsule
- Individual is aged 18 years and older

Ozurdex — Diabetic macular edema (DME)

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- ALL of the following
  - Active or suspected ocular or periocular infection
  - Glaucoma with a cup to disc ratio of greater than 0.8
- Individual is aged 18 years and older

Iluvien (fluocinolone acetonide intravitreal implant) — Diabetic Macular Edema (DME)

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- ALL of the following
  - Active or suspected ocular or periocular infection
  - Glaucoma with a cup to disc ratio of greater than 0.8
- Has previously been treated with corticosteroids and did not have a clinically significant rise in intraocular pressure
- Individual is aged 18 years and older

Iluvien — Chronic non-infectious uveitis affecting posterior segment

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- ALL of the following
  - Active or suspected ocular or periocular infection
- Has greater than or equal to 1 year history of non-infectious uveitis
- Individual is aged 18 years and older

Retisert (fluocinolone acetonide intravitreal implant) — Chronic non-infectious uveitis affecting posterior segment

Covered when ALL of the following are met:

ALL of the following

Individual is aged 12 years and older
Has greater than or equal to 1 year history of non-infectious uveitis
Does NOT have active or suspected ocular or periocular infection

Xipere (triamcinolone acetonide injectable suspension) — Macular edema associated with uveitis

Covered when ALL of the following are met:

ALL of the following

Individual is aged 18 years and older
Has a diagnosis of non-infectious uveitis
The macular edema is secondary to uveitis
Does NOT have active or suspected ocular or periocular infection

Yutiq (fluocinolone acetonide intravitreal implant) — Chronic non-infectious uveitis of the posterior segment

Covered when ALL of the following are met:

ALL of the following

Individual is aged 18 years and older
Has greater than or equal to 1 year history of non-infectious uveitis
Does NOT have active or suspected ocular or periocular infection

Background, Evidence, and Definitions

Intravitreal implants and suprachoroidal injections deliver corticosteroids to the posterior segment to reduce inflammation and improve vision in conditions such as macular edema from BRVO/CRVO, diabetic macular edema (DME), and non-infectious uveitis. The primary purpose is to provide sustained drug delivery to the vitreous or suprachoroidal space for posterior-segment disease. Key risks associated with these corticosteroid treatments include cataract formation (frequent in phakic patients receiving fluocinolone implants) and elevated intraocular pressure (IOP) — often requiring IOP-lowering medications and sometimes glaucoma surgery. Suprachoroidal administration may improve posterior exposure while potentially minimizing some side effects such as increases in eye pressure.

Evidence / Source	Summary
Ozurdex RCTs — retinal vein occlusion	Clinically meaningful improvements in visual acuity within 1–3 months versus sham; >10% greater proportion gaining ≥15 letters at 30–90 days but not at 180 days in some trials; increased cataract and elevated intraocular pressure observed.
Fluocinolone implants — uveitis RCTs	RCTs (multiple trials) support prevention of recurrence and improved visual acuity over up to 4 years; high rates of cataract formation and elevated intraocular pressure, with many requiring IOP-lowering meds and some requiring surgery.
CLS-TA Phase 3 (suprachoroidal triamcinolone)	Phase 3 RCT met primary endpoint: 47% vs 16% gained ≥15 ETDRS letters at week 24; mean CST reduction significant (153 μm vs 18 μm); no serious treatment‑related adverse events reported; steroid‑related IOP elevations similar or lower versus control.

Definitions (brief)

BCVABest corrected visual acuity

CSTCentral subfield thickness

MEMacular edema

DMEDiabetic macular edema