CommercialPrior AuthMedium impact
Verteporfin (Visudyne®)
BCBS Tennessee·TN · Ophthalmology·Medical Policy
Effective date
Sep 30, 2026
We identified it
Jul 17, 2026
Summary
BlueCross BlueShield of Tennessee has issued a new medical policy for Verteporfin (Visudyne®) effective 9/30/2026 that establishes coverage criteria for choroidal neovascularization and choroidal hemangioma treatments. The policy requires step therapy, mandates ophthalmologist prescription, limits treatment spot size to ≤6.4mm diameter, and authorizes 6-month initial coverage with 12-month continuation for demonstrated positive clinical response. This is a future-dated policy not yet implemented.
Action Required
By September 30, 2026: Billing team must implement the following changes: (1) Update billing system to require step therapy authorization per the BC Step Therapy Guide before processing Verteporfin claims; (2) Configure system to verify ophthalmologist prescriber specialty and deny claims from non-ophthalmologists; (3) Add validation rule requiring treatment spot size documentation (≤6.4mm diameter) for choroidal neovascularization claims; (4) Set authorization limits to 6 months for initial treatment and 12 months for continuation therapy; (5) Program system to require documentation of positive clinical response for any continuation authorizations beyond initial 6-month period. Prior to effective date, coordinate with providers and ophthalmology practices to communicate new authorization requirements. Failure to implement step therapy will result in claim denials.