CommercialPrior AuthMedium impact
Ranibizumab (Susvimo®)
BCBS Tennessee·TN · Ophthalmology·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 10, 2026
Summary
BlueCross BlueShield of Tennessee is establishing a new medical policy for Ranibizumab (Susvimo®), an ocular implant for three retinal conditions (wet AMD, diabetic macular edema, and diabetic retinopathy). Coverage requires prior step therapy, documented response to at least two prior VEGF inhibitor injections, and ophthalmologist prescription. The policy becomes effective December 1, 2026 and authorizes 12-month treatment periods with continuation based on demonstrated clinical response.
Action Required
By November 15, 2026: Billing and prior authorization teams must prepare for Susvimo® implementation. (1) Establish step therapy protocol requiring documentation of two prior VEGF inhibitor injections (Avastin or Eylea) within 6 months before approval. (2) Configure authorization workflow to route all Susvimo® requests to ophthalmology reviewers and require ophthalmologist prescription verification. (3) Update billing system to recognize three covered indications: wet AMD, diabetic macular edema, and diabetic retinopathy. (4) Create claim edits to verify ocular implant use (Susvimo implant must be documented with drug). (5) Train prior auth staff on step therapy requirements and 12-month authorization periods. (6) Prepare staff to deny claims for unlisted indications or those lacking prior VEGF inhibitor response documentation. Reference: https://www.bcbst.com/docs/providers/Comm_BC_PAD_Step_Therapy_Guide.pdf