Limited Coverage Drugs - Ocriplasmin

Generic Name

ocriplasmin

Strength

2.5 mg per mL
Form injection

Special Authority Criteria

Approval Period

For the treatment of symptomatic vitreomacular adhesion (VMA) confirmed through optical coherence tomography.

AND

Administered by a retinal specialist.

Excluded:

Coverage cannot be considered if patient has any of the following:

  • large diameter macular holes (> 400 micrometre), or
  • high myopia (> 8 dioptre spherical correction or axial length > 28 millimetre), or
  • aphakia, or
  • history of retinal detachment, or
  • lens zonule instability, or
  • recent ocular surgery or intraocular injection (including laser therapy), or
  • proliferative diabetic retinopathy, or
  • ischemic retinopathies, or
  • retinal vein occlusions, or
  • exudative age-related macular degeneration, or
  • vitreous hemorrhage.

One injection per eye (lifetime maximum)

Practitioner Exemptions

  • None

Special Notes

  • Special Authority requests will be accepted from retinal specialists only.

Special Authority Request Form(s)