Ocular/Otic

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®)

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®)

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 

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)

Tier 1

Tier 2

• travoprost (Travatan®, Travatan® Z)

• bimatoprost (Lumigan®)
• latanoprost (Xalatan®)
• tafluprost (Zioptan®)

Tier 1

Tier 2

• dipivefrin (Propine®)

Tier 1

Tier 2

• brimonidine 0.2%

• brimonidine (Alphagan® P 0.1%,0.15%)
• apraclonidine (Iopidine® 1%)

Tier 1

Tier 2

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

*(Indicates Available Oral Products)

• brinzolamide (Azopt®)

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®)

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 

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®)

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®)