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