Payer PolicyActive
Ranibizumab (Lucentis®, Byooviz™, and Cimerli™) Injection
EVICORE-MEDICAL_DRUG-349B25C2
EviCore by Evernorth
Effective: January 1, 2023
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Ranibizumab (Lucentis, Byooviz, Cimerli) is covered for the listed FDA‑approved indications (neovascular AMD, RVO‑related macular edema, DME, DR, mCNV) and certain compendial off‑label neovascular ophthalmic uses, with coverage limited to those diagnoses. Key requirements: documented diagnosis, administration by or under an ophthalmologist, adherence to indication‑specific intravitreal dosing (0.5 mg monthly for AMD/RVO; 0.3 mg monthly for DME/DR; 0.5 mg monthly for up to 3 months for mCNV), and approvals up to 12 months.
Coverage Criteria Preview
Key requirements from the full policy
"Myopic choroidal neovascularization (mCNV)"
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