SUSVIMO (ranibizumab)

SUSVIMO (ranibizumab)

Medical Administration – intravitreal use via ocular implant

Diagnosis considered for coverage:

Treatment of patients with Neovascular (wet) Age-related Macular Degeneration (AMD) who have previously responded to at least two intravitreal injections of a Vascular Endothelial Growth Factor (VEGF) inhibitor medication.

Coverage Criteria:

For diagnosis of Neovascular (wet) Age-related Macular Degeneration (AMD):

• Dose does not exceed 2 mg (0.02 mL of 100 mg/mL solution) every 24 weeks per affected eye; AND
• Patient has a diagnosis of neovascular (wet) age-related macular degeneration (nAMD); AND
• Prescribed by or in consultation with an ophthalmologist; AND
• Trial and positive response to at least 2 intravitreal injections of a VEGF inhibitor; AND
• A medically appropriate reason is provided why the patient cannot use the preferred vascular endothelial growth factor (VEGF) inhibitor agent(s) to treat their condition (e.g., ranibizumab [Lucentis], aflibercept [Eylea], brolucizumab-dbll [Beovu], bevacizumab [Avastin], etc.); AND
• Susvimo will not be used in combination with another intravitreal VEGF inhibitor

Reauthorization Criteria:

For diagnosis of Neovascular (wet) Age-related Macular Degeneration (AMD):

• Dose does not exceed one of the following:
  • 2 mg (0.02 mL of 100 mg/mL solution) every 24 weeks per affected eye
  • 0.5 mg (0.05 mL of 10 mg/mL) for supplemental treatment per affected eye; AND
• Documentation of positive clinical response or partial response to therapy; AND
• Susvimo will not be used in combination with another intravitreal VEGF inhibitor

Coverage Duration: 

• Initial: 1 year
• Reauthorization: 1 year

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information: 

• Your Health Maintenance Organization (HMO) may have preferred VEGF-inhibitor agents. HMO preferred agents may vary.  You will have to try their preferred agents, if any, prior to using Susvimo.
• Recommended dose: 2 mg (0.02 mL of 100 mg/mL solution) continuously delivered via the Susvimo ocular implant with refills administered every 24 weeks (approximately 6 months)
• Supplemental treatment with 0.5 mg (0.05 mL of 10 mg/mL) intravitreal ranibizumab injection may be administered in the affected eye while the Susvimo implant is in place and if clinically necessary
• Contraindications:
  • Ocular or periocular infections
  • Active intraocular inflammation
  • Hypersensitivity
• Warnings for endophthalmitis, rhegmatogenous retinal detachment, implant dislocation, vitreous hemorrhages, conjunctival erosion or retraction, conjunctival bleb, postoperative decrease in visual acuity, air bubbles causing improper filling of the implant, deflection of the implant
• The safety and efficacy of Susvimo (ranibizumab injection) in pediatric patients have not been established
• VEGF inhibitors: Aflibercept (Eylea), bevacizumab, brolucizumab (Beovu), ranibizumab (Lucentis, Susvimo)

Policy Updates:

• 5/17/2022 – New policy approved by P&T.

References:

Susvimo Prescribing Information. Genentech, Inc. South San Francisco, CA. October 2021.