Cigna: Susvimo Payer Policy (Beta Access)
TABLE OF CONTENTS
| HCPCS Code(s): | J2779 |
| Precertification Required? | Yes (Click Here for Full Policy) |
| Step Therapy Required? | Not Specified (Click Here for Full Policy) |
| Provider Fax Form: | Generic Form ✅ Available in SamaCare |
| FDA Approved Indications: | Not Specified |
| Recommended Dosage: | Not Specified |
This policy outlines the coverage criteria for Susvimo™, a vascular endothelial growth factor (VEGF) inhibitor delivered via an ocular implant. Susvimo is indicated for the treatment of neovascular (wet) age-related macular degeneration (nAMD) in patients who have previously responded to at least two intravitreal injections of a VEGF inhibitor.
Line of Business
This policy applies to health benefit plans administered by Cigna, including:
- Employer and Individual Plans
- Individual and Family Plans
The effective date is May 15, 2024, with no criteria changes noted.
Precertification/Prior Authorization
- Required: Yes, prior authorization is required for all covered indications.
Conditions Not Covered
Susvimo is considered experimental, investigational, or unproven for the treatment of:
- Neovascular (Wet) Age-Related Macular Degeneration (nAMD):
- Insufficient data on safety, particularly concerning higher ocular adverse event rates compared to Lucentis.
- Notably, endophthalmitis occurred at a threefold higher rate with Susvimo (1.7%) compared to Lucentis (0.5%).
Safety and Warnings
Susvimo has specific risks and a boxed warning regarding:
- Endophthalmitis: Higher incidence compared to other VEGF inhibitors.
- Implant-related Risks:
- Rhegmatogenous retinal detachment
- Implant dislocation
- Vitreous hemorrhage
- Conjunctival erosion or retraction
- Conjunctival bleb
- Postoperative visual acuity decrease
- Improper filling of the implant due to air bubbles
- Implant deflection
These risks and complications are unique to Susvimo and associated with its implant and procedural requirements.
Background
- Susvimo is an intravitreal implant that provides sustained delivery of ranibizumab, unlike other VEGF inhibitors administered via periodic injections.
- The pivotal trial demonstrated non-inferiority of Susvimo compared to Lucentis in visual acuity outcomes; however, safety concerns remain a significant limitation.
Sources: https://static.cigna.com/assets/chcp/pdf/coveragePolicies/pharmacy/ip_0349_coveragepositioncriteria_ranibizumab_ocular_implant.pdf
⚠️ Disclaimer: This article is a policy summary and does not guarantee coverage or approval.
Policies may vary based on plan, payer-specific rules, state or regional requirements, benefit structure, formulary placement, and patient-specific considerations like diagnosis or clinical history. Always review the full policy and confirm details directly with the payer to ensure compliance.
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