Susvimo™
Drug - Susvimo™ (ranibizumab) [Genentech, Inc.]
April 2022
Therapeutic Area - Macular Degeneration Agents
Initial approval criteria
- Patient is at least 18 years of age AND
Universal Criteria
- Patient is free of ocular and/or peri-ocular infections AND
- Patient does not have active ocular inflammation AND
- Therapy will not be used with other ophthalmic VEGF inhibitors (e.g., aflibercept, pegaptanib, brolucizumab, bevacizumab, ranibizumab) unless supplemental treatment is necessary (find more information in renewal criteria) AND
- Patient has not required removal of a Susvimo implant in the past AND
- Patient does not have a hypersensitivity to other ranibizumab products (i.e., Lucentis®, Byooviz™, etc.) AND
- Patient’s best corrected visual acuity (BCVA) is measured at baseline and periodically during treatment AND
Neovascular (Wet) Age-Related Macular Degeneration (AMD)
- Patient has previously responded to at least two intravitreal injections of a vascular endothelial growth factor (VEGF) inhibitor medication (e.g., aflibercept, pegaptanib, brolucizumab, bevacizumab, ranibizumab)
- Initial approval is for 6 months
Renewal criteria
- Patient continues to meet the universal and indication-specific relevant criteria as identified in the initial approval criteria AND
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following: endophthalmitis, rhegmatogenous retinal detachment, implant dislocation, vitreous hemorrhage, conjunctival erosion, conjunctival retraction, and conjunctival blebs, etc. AND
- Patient has had a beneficial response to therapy (e.g., improvement in the baseline best corrected visual acuity (BCVA), etc.) and continued administration is necessary for the maintenance treatment of the condition AND
- Supplemental treatment only: Patient has had an insufficient response during initial or maintenance therapy with Susvimo administered every 24 weeks and requires supplemental treatment with intravitreal ranibizumab
- Renewal approval is for 6 months
Quantity limits
Initial/Maintenance:
- 2 mg (0.02 mL of 100 mg/mL solution) continuously delivered via the Susvimo ocular implant with refills administered every 24 weeks (approximately 6 months)
Supplemental
- Supplemental treatment with 0.5 mg (0.05 mL of 10 mg/mL) intravitreal ranibizumab injection may be administered in the affected eye while the Susvimo implant is in place and if clinically necessary
Billing for Susvimo
- Susvimo must be billed as a medical claim
Questions?
MHCP Provider Resource Center 651-431-2700 or 1-800-366-5411