Product Details
Eylea HD
Aflibercept8 mg/0.07 mL
Solution for Intravitreal Injection
Single-Use 0.07-mL Vial (Preservative-Free)
DIN/PIN/NPN
02545004
Manufacturer
Bayer Inc., Health Care Division
Formulary Listing Date
2024-12-30
Unit Price
1250.0000
Amount MOH Pays
1250.0000
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
S01LA05
Interchangeable Products
NOLU Clinical Criteria
LU Code | Auth. Period | Clinical Criteria |
---|---|---|
694 | 1 year | For the treatment of patients with neovascular (wet) age-related macular degeneration (AMD) in a treatment-naive eye. Initial diagnosis should be confirmed by an appropriate diagnostic procedure and administration should be done by a qualified ophthalmologist experienced in intravitreal injections. Patients receiving concurrent administration of other anti-VEGF intravitreal injections are not eligible for reimbursement. Treatment with anti-VEGF agents should only be continued in patients who maintain adequate response to therapy. Coverage will be provided for patients responding to therapy with another anti-VEGF agent who switch to Eylea HD. Coverage will not be provided for patients who have failed to respond to other anti-VEGF agents. Recommended Dose: Treatment should be initiated with a monthly intravitreal injection for the first 3 consecutive doses, followed by one injection every 8 to 16 weeks. |
695 | 1 year | For the treatment of patients with clinically significant diabetic macular edema (DME) for whom laser photocoagulation is also indicated; and a hemoglobin A1c of less than 12 percent. Patients receiving concurrent administration of other anti-VEGF intravitreal injections are not eligible for reimbursement. Treatment with anti-VEGF agents should only be continued in patients who maintain adequate response to therapy. Coverage will be provided for patients responding to therapy with another anti-VEGF agent who switch to Eylea HD. Coverage will not be provided for patients who have failed to respond to other anti-VEGF agents. Recommended Dose: Treatment should be initiated with a monthly intravitreal injection for the first 3 consecutive doses, followed by one injection every 8 to 16 weeks. |