Payer PolicyActive
Verteporfin (Visudyne)
EVICORE-MEDICAL_DRUG-63DB67BC
EviCore by Evernorth
Effective: December 1, 2018
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Visudyne (verteporfin) is covered only for predominantly classic subfoveal choroidal neovascularization due to age-related macular degeneration, pathologic myopia, or presumed ocular histoplasmosis, and is not covered for other etiologies or in patients with porphyria. Coverage requires documentation of diagnosis and etiology and absence of porphyria, adherence to dosing and administration (6 mg/m2 IV with photodynamic light therapy 15 minutes after infusion start), and authorization is limited to 12 months.
Coverage Criteria Preview
Key requirements from the full policy
"Treatment of individuals with predominantly classic subfoveal choroidal neovascularization"
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