Non-Group Coverage (Group 1) Coverage for Seniors (Group 66) Palliative Coverage (Group 20514, Please note your client may have Group 1 or Group 66 coverage) Child and Family Services (Group 20403) Alberta Child Health Benefit (Group 20400) Children and Youth Services (Group 19824) Income Support (Group 19823) Alberta Human Services (AISH) (Group 19823) Alberta Adult Health Benefit (AAHB) (Group 23609)
Special Authorization Request Form:
N/A
RESTRICTED BENEFIT
This Drug Product is a benefit to a member of an Alberta Government Sponsored Drug Plan when the Drug Product is prescribed by a registered prescriber and pursuant to the following criteria:
"For the treatment of neovascular (wet) age-related macular degeneration (AMD) if all of the following apply to the eye to be treated:
- The best corrected visual acuity (BCVA) is between 6/12 (20/40) and 6/96 (20/320); and - There is active disease activity (choroidal neovascularization) and no permanent structural damage to the central fovea; and - There is evidence of recent (< three (3) months) presumed disease progression (blood vessel growth, as indicated by fluoroscein angiography, optical coherence tomography (OCT) or recent visual acuity changes); and - No concurrent verteporfin PDT treatment; and - The injection will be administered by a qualified ophthalmologist with experience in intravitreal injections.
Treatment with anti-VEGF agents should be continued only in patients who maintain adequate response to therapy.
The anti-VEGF agent should be discontinued if any of the following occur: - Reduction in BCVA in the treated eye to less than fifteen (15) letters (absolute) on two (2) consecutive visits in the treated eye, attributed to AMD in the absence of other pathology; or - Reduction in BCVA of thirty (30) letters or more compared to either baseline and/or best recorded level since baseline as this may indicate either poor treatment effect or adverse event or both; or - There is evidence of deterioration of the lesion morphology despite optimum treatment over three (3) consecutive visits.
The interval between the doses should be no less than 1 month.
Coverage will not be provided for patients who have failed to respond to a previous anti-VEGF agent."
"For the treatment of diabetic macular edema (DME), in patients with severe visual impairment as defined by:
Best-Corrected Visual Acuity (using the Early Treatment Diabetic Retinopathy Study visual acuity test) of seventy-eight (78) to twenty-four (24) letters and a central retinal thickness greater than or equal to three hundred (300) micrometres meeting all of the following criteria: - clinically significant diabetic macular edema for whom laser photocoagulation is also indicated, and - a hemoglobin A1c of less than or equal to 12%.
Coverage will not be provided to patients who have failed to respond to a previous anti-VEGF agent."
"For the treatment of visual impairment due to macular edema secondary to central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO).
Aflibercept is administered by intravitreal injection once every month. The interval between doses should not be shorter than one month. The treatment interval may be extended up to 3 months based on visual and anatomic outcomes. Prescribers are advised to periodically assess the need for continued therapy.
Clinical trial experience of a monthly dosing regimen of 2 mg aflibercept beyond 6 months in the CRVO and BRVO indications is limited. The dosing regimen of once every 4 weeks changed, at 24 weeks, to a regimen that allowed for extension of the treatment based on visual and anatomic outcomes in the CRVO clinical trials and to once every 8 weeks in the BRVO clinical trial.
Coverage will not be provided for patients who have failed to respond to a previous anti-VEGF agent."
CDR - List with clinical criteria and/or conditions
BAYER INC. (BAI)
Telephone:(905) 282-5550
Toll-Free:(800) 622-2937
To return to the printable Drug Benefit List and related publications,
click here
Last Updated:
NOTICE:
The DBL, DBS and related publications require knowledgeable interpretation and are intended primarily for professional health care practitioners, pharmacies, hospitals and organizations associated with the manufacture, distribution and use of pharmaceutical preparations.
Electronic versions of all DBL and DBS related publications are unofficial versions and are provided for convenience and private use only. Official paper versions can be obtained from Alberta Blue Cross who publishes them on behalf of Alberta Health and Alberta Human Services.
Alberta Health reserves the right to make changes, without notice, to the List through the Interactive DBL(iDBL), and any such changes to the Interactive DBL(iDBL) are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper version or updates.