Lucentis

Drug - Lucentis (ranibizumab) [Genentech Inc.]

April 2020

Therapeutic area - Macular Degeneration Agents

Initial approval criteria

• Patient is 18 years or older AND
• Patient is free of ocular and/or peri-ocular infections AND
• Lucentis is prescribed by an ophthalmologist AND
• Therapy will not be used with other ophthalmic VEGF inhibitors AND
• Patient has a definitive diagnosis of one of the following:
  • Neovascular (Wet) Age-Related Macular Degeneration (AMD)
  • Diabetic Macular Edema (DME)
  • Diabetic Retinopathy (DR)
  • Macular Edema following Retinal Vein Occlusion (RVO)
  • Myopic Choroidal Neovascularization (mCNV)
• Initial approval for mCNV will be for 3 months
• Initial approval for AMD, DME, DR or RVO will be for 12 months

Renewal criteria

• Patient continues to meet initial approval criteria AND
• Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following: endophthalmitis and retinal detachments; increase in intraocular pressure; arterial thromboembolic events AND
• Patient had a beneficial response to therapy AND
  • Continued administration is necessary for the maintenance treatment of the condition
    OR
  • Myopic choroidal neovascularization ONLY
    • Continued administration is necessary due to disease activity (i.e., drop in vision, visual symptoms (e.g., metamorphopsia), or the presence of intra-/sub-retinal fluid or active leakage)
• Renewal approval for mCNV will be for 3 months
• Renewal approval for AMD, DME, DR or RVO will be for 12 months

Quantity limits

• Neovascular (Wet) Age-Related Macular Degeneration (AMD): 0.5mg every 28 days
• Diabetic Macular Edema (DME): 0.3mg every 28 days
• Diabetic Retinopathy (DR): 0.3mg every 28 days
• Macular Edema following Retinal Vein Occlusion (RVO): 0.5mg every 28 days
• Myopic Choroidal Neovascularization (mCNV): 0.5mg every 28 days

Billing for Lucentis

Lucentis must be billed as a medical claim.

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411