Subject: Jetrea 3000-A SGM P2021

Drug

JETREA  (ocriplasmin intravitreal injection)

Policy:

      I.  INDICATIONS

           The indications below including FDA-approved indications and compendial uses are
           considered a covered benefit provided that all the approval criteria are met and the member
           has no exclusions to the prescribed therapy.

           FDA-Approved Indication
           Jetrea is indicated for the treatment of symptomatic vitreomacular adhesion.

           All other indications are considered experimental/investigational and not medically
           necessary.

     
    II.  CRITERIA FOR INITIAL APPROVAL

          Vitreomacular adhesion
          Authorization of 90 days for a single dose (for each eye) may be granted for treatment of
          symptomatic vitreomacular adhesion.

 

 

          

 

Place of Service:

Outpatient

The above policy is based on the following references:

I.  REFERENCES

 

1. Jetrea [package insert]. Iselin, NJ: ThromboGenics, Inc; February 2017.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

August 24, 2021