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Ocular/Otic

Ocular Allergy

Tier 1 products are covered with no authorization necessary

Tier 2 authorization criteria

  • FDA approved diagnosis
  • A trial of one tier 1 product for a minimum of two weeks in the last 30 days that did not yield adequate relief of symptoms or resulted in intolerable adverse effects
  • Contraindication to lower tiered medications

Tier 3 authorization criteria

  • FDA approved diagnosis
  • Recent trials of one tier 1 product and all available tier 2 medications for a minimum of two weeks each that did not yield adequate relief of symptoms or resulted in intolerable adverse effects.
  • Contraindication to lower tiered medications
  • Prior Authorization form 

Tier 1

Tier 2

Tier 3

  • ketotifen (Alaway®, Zaditor OTC®)
  • cromolyn (Crolom®)
  • olopatadine (Patanol®)
  • pemirolast (Alamast®)
  • nedocromil (Alocril®)
  • lodoxamide (Alomide®)
  • loteprednol (Alrex®)
  • bepotastine (Bepreve®)
  • epinastine (Elestat®)
  • emadastine (Emadine®)
  • alcaftadine (Lastacaft®)
  • azelastine (Optivar®)
  • olopatadine (Pataday®)
Otic Anti-Infective

Tier 1 products are covered with no authorization necessary

Tier 2 authorization criteria:

  • Members must have adequate 14 day trial of at least two tier 1 medications, or
  • Approval may be granted if there is a unique FDA approved indication not covered by tier 1 products or infection by organism not known to be covered by any of the tier 1 agents.
  • A ciprofloxacin combination may be approved after a recent 7 to 10 day trial of ofloxacin and dexamethasone 0.1% solution.
  • Prior Authorization form 

Tier 1

Tier 2

Special Criteria Applies

  • ofloxacin (Floxin® Otic)
  • neomycin, polymixin B, HC(Cortisporin®, Cortomycin®, Pediotic®)
  • chloroxylenol/pramoxine (Pramotic®)
  • acetic acid (Vosol®, Acetasol®)
  • ciprofloxacin, Dex or HC  (Ciprodex®, Cipro® HC, Cetraxal® Drop)
  • neomycin, colistin, HC (Coly-Mycin®, & Coly Mycin®-ES)
  • neomycin, polymixin B, HC, thonzonium (Cortisporin®TC)
  • chloroxylenol, benzocaine & HC (Trioxin®)
  • chloroxylenol/pramoxine/zinc (Zinotic®, Zinotic® ES, Chlorpram® Z)
  • acetic acid, antpy bcain polico al acet 5.4%-1.4% drops
  • acetic acid, HC (Acetasol® HC, Vosol HC)
  • acetic acid,aluminum (Borofair®)
  • antipyrine, benzocaine, glycerin,zinc 5.4-1-2-1% (Neotic®)
Ophthalmic Glaucoma Medications

Tier 1 products are covered with no authorization necessary

Tier 2 authorization requires:

  • Comprehensive dilated eye exam within the last 365 day period, and
  • FDA-approved indication, and
  • Member must attempt at least three tier 1 products for a minimum of 4 weeks in duration each within the last 120 days. Tier 1 trails may be from any pharma logic class, or
  • Documented adverse effect, drug interaction, or contraindication to Tier 1 products, or
  • Unique FDA-approved indication for which Tier 1 medications are not indicated
  • Prior Authorization form 
Beta-Blockers

Tier 1

Tier 2

  • levobunolol (Betagan®)
  • timolol maleate (Betimol®, Istalol®, Timoptic®, Timoptic Ocudose®, Timoptic® XE)
  • betaxolol (Betoptic® 0.5%)
  • dorzolamide/timolol (Cosopt®)
  • carteolol (Ocupress®)
  • metipranolol (OptiPranolol®)
  • betaxolol (Betoptic® S)
  • brimonidine/timolol (Combigan®)
  • timolol maleate (Timoptic® 0.5% dropperette)
Prostaglandin Analogs

Tier 1

Tier 2

  • travoprost (Travatan®, Travatan® Z)
  • bimatoprost (Lumigan®)
  • latanoprost (Xalatan®)
  • tafluprost (Zioptan®)
Adrenergic Agonists

Tier 1

Tier 2

  • dipivefrin (Propine®)
Alpha-2 Adrenergic Agonists

Tier 1

Tier 2

  • brimonidine 0.2%
  • brimonidine (Alphagan® P 0.1%,0.15%)
  • apraclonidine (Iopidine® 1%)
Carbonic Anhydrase Inhibitors

Tier 1

Tier 2

  • dorzolamide/timolol (Cosopt®)
  • dorzolamide (Trusopt®)
  • dichlorphenamide (Daranide®)*
  • acetazolamide (Diamox®)
  • methazolamide (Neptazane®)*

*(Indicates Available Oral Products)

  • brinzolamide (Azopt®)
Cholinergic Agonists/Cholinesterase Inhibitors

Tier 1

Tier 2

  • pilocarpine (Isopto Carpine®, Pilopine® HS 0.5%, 1%,2%,4%,6%)
  • carbachol (Isopto®, Miostat® 1.5%, 3%)
  • echothiophate iodide (Phospholine lodide®)
Ophthalmic Anti-Infective/Steroid Combinations

All steroid combinations listed below will require a petition for use and the PA Criteria is as follows:

  • Used for pre-operative/post-operative prophylaxis®
  • Prescription written by optometrist / ophthalmologist
    • tobramycin/dexamethasone (Tobradex®)
    • tobramycin/loteprednol (Zylet®)
    • sulfacetamide/prednisolone (Blephamide®)
    • gentamicin/prednisolone (Pred-G®)
    • neomycin/polymyxin/Bac/Hydrocortisone Ointment
    • neomycin/polymyxin-B/prednisolone (Poly-Pred®)
    • neomycin/polymyxin-B/hydrocortisone (Cortisporin®)
    • neomycin/polymyxin-B/dexamethasone (Maxitrol®)
  • Prior Authorization form  

Tier 1 products are covered with no authorization necessary

Criteria for a Tier 2 medication:

  • Approved indication/suspected infection by organism not know to be covered by tier 1 products,or failure of a tier 1 products
  • Known contraindication to all indicated tier 1 medication.
  • Prescription written by optometrists/ophthalmologists, or
  • When used for pre/post-operative prophylaxis.

Criteria for a Tier 3 medication:

  • Approved indication/suspected infection by organism not know to be covered by tier 2 products, or failure of a tier 2 product.
  • Known contraindication to all indicated tier 2 medication.
  • Prescription written by optometrists/ophthalmologists, or
  • When used for pre/post-operative prophylaxis.
  • Prior Authorization form 
Ophthalmic Antibiotics: Liquids

Tier 1

Tier 2

Tier 3

  • gentamicin (Gentak®)
  • neomycin/polymyxinB/ gramacidin (AK-spore®)
  • polymyxinB/trimethoprim  (Polytrim®)
  • sodium sulfacetamide (Blehp-10, Sodium Sulamyd ®)
  • tobramycin (AK-tob ®)
  • ciprofloxacin(Ciloxan®)
  • ofloxacin (Ocuflox®)
  • azithromycin (Azasite®)
  • besifloxacin HCL (Besivance®)
  • gatifoxacin (Zymaxid®) 
  • gatifoxacin (Zymar®)
  • levofloxacin (Quixin®)
  • levofloxacin (lquix®)
  • moxifloxacin (Vigamox®)
Ophthalmic Antibiotics: Ointments

Tier 1

Tier 2

  • bacitracin (AK-tracin®)
  • bacitracin/polymyximB (AK-poly-bac ®)
  • erythromycin (A/T/S®, Ilotycin®, Roymicin®)
  • gentamicin (Gentak®)
  • neomycin/polymyxin B/bacitracin (Neosporin®)
  • sodium sulfacetamide (Bleph-10, Sodium Sulyamyd®)
  • tobramycin (Tobrex®)
  • ciprofloxacin (Ciloxan ointment®)

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.

Last Modified on Dec 21, 2020
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