Photrexa – Enhanced & Essential

Restricted Products:

• Photrexa® viscous (riboflavin 5’-phosphate)
• Photrexa® (riboflavin 5’-phosphate)

FDA Approved Use:

• Indicated for use with the KXL system in corneal collagen cross-linking for the treatment of progressive keratoconus and corneal ectasia following refractive surgery.

Criteria for Approval of Restricted Product(s):

Initial Coverage

1. The patient is 14 years of age or older; AND
2. The patient has been diagnosed with ONE of the following (medical documentation required);
   1. Progressive keratoconus; OR
   2. Corneal ectasia following refractive surgery; AND
3. The patient will use Photrexa in combination with corneal cross-linking procedure; AND
4. The prescribed dose and quantity are appropriate based on intended use and FDA labeling; AND
5. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.

Duration of Approval: 30 days

References:

All information referenced is from FDA package insert unless otherwise noted below.

Policy Implementation/Update Information:

July 2022: Original utilization management policy issued.