Ocriplasmin (Jetrea)

Covered: one 0.125 mg intravitreal injection of ocriplasmin (Jetrea) for the FDA‑approved indication of symptomatic vitreomacular adhesion in patients ≥18 years; other indications are not covered, repeat dosing in the same eye is prohibited, and treatment of the fellow eye is not recommended within 7 days. Required documentation: symptomatic VMA diagnosis, patient age ≥18, confirmation no prior Jetrea in the treated eye, timing if treating the contralateral eye, and the administered dose/route (0.125 mg intravitreal).

"≥ 18 years of age."

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