Medicare AdvantagePrior AuthMedium impact
Ozurdex® (dexamethasone intravitreal implant) (Revised)
Humana·FL, KY, SC · Ophthalmology·Medicaid
Effective date
Nov 26, 2025
We identified it
Jun 25, 2026
Summary
This is a routine policy revision for Ozurdex (dexamethasone intravitreal implant) covering three indications: macular edema from retinal vein occlusion, non-infectious posterior segment uveitis, and diabetic macular edema. The policy requires prior authorization for all three indications across Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina) with consistent exclusion criteria (advanced glaucoma, aphakic eyes with posterior lens capsule rupture, ACIOL with posterior lens capsule rupture).
Action Required
By November 26, 2025: Billing team must verify that the practice's prior authorization workflows for Ozurdex injections are updated to reflect the three covered indications and three exclusion criteria. For claims submitted to Humana Medicare Advantage, Medicaid-Florida, Medicaid-Kentucky, or Medicaid-South Carolina: (1) Confirm that prior authorization is being requested before service delivery or at claim submission; (2) Verify that clinical documentation includes diagnosis of BRVO, CRVO, non-infectious posterior segment uveitis, OR diabetic macular edema; (3) Confirm that exclusion criteria (advanced glaucoma, aphakic eyes with ruptured posterior lens capsule, ACIOL with ruptured posterior lens capsule) are screened and documented; (4) Update claim submission templates to flag Ozurdex injections for prior authorization review. Reference www.humana.com/PAL for current medical and procedural coding requirements. Failure to obtain prior authorization may result in claim denials. Note: Approval duration is determined by clinical review or plan year duration—do not assume multi-year approvals.