Ocular/Otic 2019

Tier 1 products are covered with no authorization necessary

Tier 2 authorization criteria

• FDA approved diagnosis; AND
• A trial of one Tier-1 medication 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; OR
• A contraindication to all lower tiered medications

Tier 3 authorization criteria

• An FDA approved diagnosis; AND
• Recent trials of one Tier-1 medication and all available Tier-2 medications for a minimum of two weeks that did not yield adequate relief of symptoms or resulted in intolerable adverse effects; OR
• A contraindication to all lower tiered medications 

Prior Authorization form   

Tier 1

Tier 2

Tier 3

• cromolyn (Crolom®)
• ketotifen (Alaway®, Zaditor OTC®)

• azelastine (Optivar®)
• epinastine (Elestat®)
• olopatadine (Patanol®) 

• alcaftadine (Lastacaft®)
• bepotastine (Bepreve®)
• cetirizine (Zerviate™)
• emadastine (Emadine®)
• lodoxamide (Alomide®)
• loteprednol (Alrex®)
• nedocromil (Alocril®)
• olopatadine (Pataday®)
• olopatadine hydrochloride (Pazeo™) 

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.

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.

Special Prior Authorization (PA) Approval Criteria:

• An FDA approved diagnosis; AND
• A patient-specific, clinically significant reason why a special formulation is needed over a Tier-1 or Tier-2 product; OR
• Approvals may be granted if there is a documented adverse effect, drug interaction, or contraindication to all Tier-1 and Tier-2 medications; OR
• Approvals may be granted if there is a unique FDA approved indication not covered by all Tier-1 and Tier-2 medications; AND
• The member must have had a comprehensive, dilated eye exam within the last 365-day period as recommended by the National Institute of Health; AND
• Approvals will be for the duration of one year.

Prior Authorization form  

Tier 1

Tier 2

Special PA

Alpha-2 Adrenergic Agonists

• brimonidine (Alphagan® 0.2%) 
• brimonidine (Alphagan-P® 0.1%) 
• brimonidine/timolol (Combigan®) 
• brinzolamide/brimonidine (Simbrinza®)

•apraclonidine (Iopidine®)

• brimonidine (Alphagan-P® 0.15%)

Beta-Blockers

• brimonidine/timolol (Combigan®)
• carteolol (Ocupress® 1%)
• dorzolamide/timolol (Cosopt®)
• levobunolol (Betagan®)
• timolol maleate (Istalol®, Timoptic®)

• betaxolol (Betoptic® 0.5%, Betoptic-S®)

• dorzolamide/timolol (Cosopt® PF)
• timolol maleate (Timoptic Ocudose®, Timoptic-XE®)

Carbonic Anhydrase Inhibitors

• acetazolamide (Diamox®)
• brinzolamide (Azopt®)
• brinzolamide/brimonidine (Simbrinza®)
• dorzolamide (Trusopt®)
• dorzolamide/timolol (Cosopt®) 

• dorzolamide/timolol (Cosopt® PF)
• methazolamide (Neptazane®)

Cholinergic Agonists/Cholinesterase Inhibitors

• echothiophate iodide (Phospholine Iodide®)

• pilocarpine (Isopto® Carpine®, Pilopine HS®)

Prostaglandin Analogs

• latanoprost (Xalatan®)
• travoprost (Travatan-Z® 0.004%)

• bimatoprost (Lumigan®)
• tafluprost (Zioptan™)

• latanoprost (Xelpros™ 0.005%) 
• latanoprostene bunod (Vyzulta™)

Rho Kinase Inibitors

• netarsudil (Rhopressa®)
• netarsudil/latanoprost (Rocklatan™)

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

• ciprofloxacin(Ciloxan®)
• gentamicin (Gentak®)
• neomycin/polymyxinB/ gramicidin (Neosporin®)
• ofloxacin (Ocuflox®)
• polymyxinB/trimethoprim  (Polytrim®)
• sodium sulfacetamide (Blehp-10®)
• tobramycin (Tobrex®)

• levofloxacin (Quixin®)

• azithromycin (Azasite®)
• besiflloxacin HCL (Besivance®)
• gatifloxacin (Zymaxid®) 
• levofloxacin (lquix®)
• moxifloxacin (Vigamox®) 

Tier 1

Tier 2

• bacitracin/polymyximB (AK-poly-bac ®)
• erythromycin (A/T/S®, Ilotycin®, Roymicin®)
• gentamicin (Gentak®)
• neomycin/polymyxin B/bacitracin (Neosporin®)
• tobramycin (Tobrex®)

• bacitracin (AK-tracin®)
• ciprofloxacin (Ciloxan ointment®)
• sodium sulfacetamide (Bleph-10)