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Ocriplasmin for Symptomatic Vitreomacular Adhesion

Blue Cross & Blue Shield of Mississippi·MS · Ophthalmology·Medical Policy
Effective date
Not stated
We identified it
Jun 20, 2026
Days to comply

Summary

This is a policy review with no changes - BCBS MS confirmed their existing coverage policy for ocriplasmin (Jetrea) remains unchanged, covering single intravitreal injections for symptomatic vitreomacular adhesion/traction. Note that ocriplasmin manufacturing was discontinued in the US since 2020, making this largely academic.

Action Required

Action needed
No immediate action required - this is a policy review with no changes. The drug remains discontinued in the US since 2020, so billing scenarios are unlikely. If encountered, verify patient meets eligibility criteria including OCT demonstration of vitreous adhesion within 6mm of fovea and visual acuity of 20/25 or worse.

Affected Billing Codes

67028
J7316
H43.821
H43.822
H43.823
H43.824
H43.825
H43.826
H43.827
H43.828
H43.829