Payer PolicyActive
Susvimo® (ranibizumab intravitreal injection via ocular implant)
EVICORE-MEDICAL_DRUG-2E4B2168
EviCore by Evernorth
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Susvimo is effectively excluded from approval under these guidelines despite its FDA indication for neovascular (wet) AMD in patients who previously responded to ≥2 intravitreal VEGF injections, due to safety concerns including a boxed warning for endophthalmitis. If considered, documentation must show the FDA‑approved diagnosis of wet AMD and prior response to at least two intravitreal VEGF injections.
Coverage Criteria Preview
Key requirements from the full policy
"When requesting Susvimo (ranibizumab intravitreal injection via ocular implant), the individual requiring treatment must be diagnosed with an FDA-approved indication and meet the specific coverage ..."
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