Payer PolicyActive
Pegaptanib Sodium (Macugen)
EVICORE-MEDICAL_DRUG-EEC733FB
EviCore by Evernorth
Effective: November 1, 2020
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Macugen (pegaptanib) is covered only for the FDA‑approved indication of neovascular (wet) AMD and specified compendial off‑label neovascular ophthalmic conditions (e.g., diabetic retinopathy, neovascular glaucoma, retinopathy of prematurity, sickle cell neovascularization, choroidal neovascular conditions); other uses are not covered. Approval requires administration by or under the supervision of an ophthalmologist, documentation of the diagnosis and treatment plan, dosing of 0.3 mg intravitreous every 6 weeks, and is authorized for up to 12 months.
Coverage Criteria Preview
Key requirements from the full policy
"Macugen is indicated for the treatment of neovascular (wet) age-related macular degeneration (AMD)."
Sign up to see full coverage criteria, indications, and limitations.