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BCBS TennesseeCommercial · Prior Auth · Medical Policy · TN · OphthalmologyMedium impact

Ranibizumab (Susvimo®)

Act
by Nov 15, 2026
Effective date
Dec 1, 2026
Identified
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.

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What to do

by Nov 15, 2026 · 8 steps
01Billing and prior authorization teams must prepare for Susvimo® implementation.
02Establish step therapy protocol requiring documentation of two prior VEGF inhibitor injections (Avastin or Eylea) within 6 months before approval.
03Configure authorization workflow to route all Susvimo® requests to ophthalmology reviewers and require ophthalmologist prescription verification.
04Update billing system to recognize three covered indications: wet AMD, diabetic macular edema, and diabetic retinopathy.
05Create claim edits to verify ocular implant use (Susvimo implant must be documented with drug).
06Train prior auth staff on step therapy requirements and 12-month authorization periods.
07Prepare staff to deny claims for unlisted indications or those lacking prior VEGF inhibitor response documentation.
08Reference: https://www.bcbst.com/docs/providers/Comm_BC_PAD_Step_Therapy_Guide.pdf

Original notice

Ranibizumab (Susvimo®)
bcbst.com · Always check the source before changing claims.
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BCBS Tennessee policiesTN policy changesOphthalmology

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