Visudyne® (verteporfin)
Code(s): J3396
Benefit: Medical
Notes: Intravenous Powder for Solution: 15 MG
Criteria for coverage:
-
No PA for Commercial for the following diagnoses:
B39.4 Histoplasmosis capsulati, unspecified
B39.5 Histoplasmosis duboisii
H32 Chorioretinal disorders in diseases classified elsewhere
H35.3210-H35.3233 Exudative age-related macular degeneration
H35.711 – H35.713 Central serous chorioretinopathy
H44.20-H44.23 Degenerative myopia