Limited Coverage Drugs - Ocriplasmin

Generic Name



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.


Administered by a retinal specialist.


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)