Payer PolicyActive
Ranibizumab Implant (Susvimo®)
EVICORE-MEDICAL_DRUG-044AB4F7
EviCore by Evernorth
Effective: March 1, 2022
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Approval is not recommended for Susvimo due to significant safety concerns (Boxed Warning for endophthalmitis); use is limited to the FDA‑approved indication and non‑FDA uses are not supported. Key requirements: patient must have neovascular (wet) AMD with documented response to at least two prior intravitreal anti‑VEGF injections, with documentation of diagnosis, prior treatment dates/agents/evidence of response, and acknowledgement of the safety risks.
Coverage Criteria Preview
Key requirements from the full policy
"Susvimo is indicated for the treatment of patients with Neovascular (wet) Age-related Macular Degeneration (AMD) who have previously responded to at least two intravitreal injections of a Vascular ..."
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