Skip to content
The Policy VaultThe Policy Vault

Lucentis — Medica

any FDA-approved indication(s) for ranibizumab products (diabetic macular edema, diabetic retinopathy, macular edema following retinal vein occlusion, myopic choroidal neovascularization, neovascular [wet] age-related macular degeneration)

Preferred products

  • Byooviz
  • Cimerli

Initial criteria

  • Patient meets the standard Ophthalmology – Vascular Endothelial Growth Factor Inhibitors – Ranibizumab Products Prior Authorization Policy criteria; AND
  • Patient has tried Byooviz; AND
  • Patient cannot continue to use Byooviz due to a formulation difference in the inactive ingredient(s) [e.g., differences in stabilizing agent, buffering agent, and/or surfactant] which, according to the prescriber, would result in a significant allergy or serious adverse reaction; AND
  • Patient has tried Cimerli; AND
  • Patient cannot continue to use Cimerli due to a formulation difference in the inactive ingredient(s) [e.g., differences in stabilizing agent, buffering agent, and/or surfactant] which, according to the prescriber, would result in a significant allergy or serious adverse reaction

Approval duration

1 year