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Ocular/Otic 2019

 

Ocular Allergy

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™) 
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.

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.

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™)
 
Ophthalmic Anti-Infective/Steroid Combinations

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

  • 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®) 
Ophthalmic Antibiotics: Ointments

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)

 

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

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