Payer PolicyActive
Pegaptanib Sodium (Macugen)
EVICORE-MEDICAL_DRUG-68727A19
EviCore by Evernorth
Effective: December 1, 2018
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Pegaptanib (Macugen) is covered for neovascular (wet) age-related macular degeneration (FDA‑approved) and for diabetic macular edema (off‑label compendial use) but is excluded in the presence of ocular or periocular infection. Approval requires documentation of the diagnosis and that all coverage/safety criteria are met, limits dosing to 0.3 mg intravitreal every 6 weeks, and is authorized for up to 12 months.
Coverage Criteria Preview
Key requirements from the full policy
"Neovascular (Wet) age-related macular degeneration (AMD) (FDA-approved indication)"
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