Ocular/Otic

acyclovir 3% ophthalmic ointment (Avaclyr™) Approval Criteria:  

• An FDA approved diagnosis of acute herpetic keratitis (dendritic ulcers) in patients with herpes simplex virus (HSV); AND
• A patient-specific, clinically significant reason why the member cannot use trifluridine 1% ophthalmic solution must be provided; AND
• A patient-specific, clinically significant reason why the member cannot use oral acyclovir, famciclovir, or valacyclovir must be provided.    

Prior Authorization form   

Cystadrops^® (Cysteamine 0.37% Ophthalmic Solution) and Cystaran™ (Cysteamine 0.44% Ophthalmic Solution) Approval Criteria:

• An FDA approved indication for the treatment of corneal cystine crystal accumulation in members with cystinosis; and
• The requested medication must be prescribed by, or in consultation with, an ophthalmologist; and
• Prescriber must verify that the member has been counseled on the proper storage of the requested medication; and
• For Cystadrops^®, a patient-specific, clinically significant reason (beyond convenience) why the member cannot use Cystaran™ must be provided; and
• A quantity limit of 4 bottles per month will apply. 

Dextenza® (Dexamethasone Ophthalmic Insert) Approval Criteria:

• An FDA approved indication of the treatment of ocular inflammation and pain following ophthalmic surgery; AND
• Prescriber must verify that Dextenza® will be placed by a physician immediately following ophthalmic surgery; AND
• Date of ophthalmic surgery must be provided; AND
• A patient-specific, clinically significant reason why corticosteroid ophthalmic preparations, such as solution or suspension, typically used following ophthalmic surgery are not appropriate for the member must be provided; AND
• A quantity limit of 1 insert per eye every 30 days will apply.

Prior Authorization form

Eysuvis^® (Loteprednol 0.25% Ophthalmic Suspension) Approval Criteria:

• An FDA approved indication for the short-term (up to 2 weeks) treatment of the signs and symptoms of dry eye disease (DED); and
• A documented trial of intermittent or regular artificial tear use within the past 3 months; and
• A patient-specific, clinically significant reason why the member cannot use Restasis^® (cyclosporine 0.05% ophthalmic emulsion), which is available without a prior authorization, must be provided; and
• A patient-specific, clinically significant reason why the member cannot use Tier-1 ophthalmic corticosteroids including Lotemax^® (loteprednol 0.5% suspension) must be provided; and
• Member must not have any contraindications to Eysuvis^®; and
• A quantity limit of 8.3mL per 15 days will apply (Eysuvis^® for the treatment of DED is not indicated for use beyond 15 days).

Iluvien® (Fluocinolone Intravitreal Implant) Approval Criteria: 

• An FDA approved diagnosis of diabetic macular edema (DME) in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure; AND
• Iluvien® must be administered by an ophthalmologist; AND
• Prescriber must verify that the member will be monitored for increased intraocular pressure, endophthalmitis, and cataract development; AND  
• A patient-specific, clinically significant reason why the member requires Iluvien® in place of corticosteroid ophthalmic preparations, such as solution or suspension, must be provided; AND
• A quantity limit of 1 implant per eye every 36 months will apply.   

Prior Authorization form   

Lucentis^® (Ranibizumab Intravitreal Injection) Approval Criteria:

• An FDA approved indication of 1 of the following; AND
• A patient-specific, clinically significant reason why the member cannot use Byooviz™ (ranibizumab-nuna intravitreal injection) or Cimerli™ (ranibizumab-eqrn intravitreal injection) must be provided. Biosimilars and/or reference products are preferred based on the lowest net cost product(s) and may be moved to either preferred or non-preferred if the net cost changes in comparison to the reference product and/or other available biosimilar products. 

cenegermin-bkbj (Oxervate™) Approval Criteria:   

• An FDA approved diagnosis of neurotrophic keratitis; AND
• Oxervate™ must be prescribed by, or in consultation with, an ophthalmologist; AND
• Prescriber must verify that the member has persistent epithelial defect (PED) (stage 2 disease) or corneal ulceration (stage 3 disease) of at least 2 weeks duration that is refractory to 1 or more conventional non-surgical treatments for neurotrophic keratitis; AND  
  • Specific non-surgical treatments and dates of trials must be listed on the prior authorization request; AND 
• Prescriber must verify that the member has evidence of decreased corneal sensitivity within the area of the PED or corneal ulcer and outside of the area of the defect in at least 1 corneal quadrant; AND
• Prescriber must verify the member has been counseled on the proper administration and storage of Oxervate™; AND
• Approvals will be for a maximum duration of 8 weeks of total therapy per eye; AND
• A quantity limit of 2 weekly kits per 14 days will apply. A quantity limit override will be approved for 4 weekly kits per 14 days with prescriber documentation of treatment in both eyes. 

Prior Authorization form

Ozurdex® (Dexamethasone Intravitreal Implant) Approval Criteria: 

• An FDA approved indication of 1 of the following:
  • The treatment of macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO); OR  
  • The treatment of non-infectious uveitis affecting the posterior segment of the eye; OR
  • The treatment of diabetic macular edema; AND
• Ozurdex® must be administered by an ophthalmologist; AND
• Prescriber must verify that the member will be monitored for increased intraocular pressure, endophthalmitis, and cataract development; AND
• Prescriber must agree to periodically monitor the integrity of the implant by visual inspection; AND
• A patient-specific, clinically significant reason why the member requires Ozurdex® in place of corticosteroid ophthalmic preparations, such as solution or suspension, must be provided; AND
• A quantity limit of 1 implant per eye every 3 months will apply.    

Prior Authorization form   

Retisert® (Fluocinolone Intravitreal Implant) Approval Criteria:

• An FDA approved diagnosis of chronic, non-infectious posterior uveitis; AND
• Retisert® must be administered by an ophthalmologist; AND
• Prescriber must verify that the member will be monitored for increased intraocular pressure, endophthalmitis, and cataract development; AND  
• Prescriber must agree to periodically monitor the integrity of the implant by visual inspection; AND
• A patient-specific, clinically significant reason why the member requires Retisert® in place of corticosteroid ophthalmic preparations, such as solution or suspension, must be provided; AND
• A patient-specific, clinically significant reason why the member requires Retisert® in place of Ozurdex® or Yutiq™ must be provided; AND  
• A quantity limit of 1 implant per eye every 30 months will apply.    

Prior Authorization form   

Susvimo™ (Ranibizumab Intravitreal Implant) Approval Criteria:

• An FDA approved indication for the treatment of adults with neovascular (wet) age-related macular degeneration (AMD); and
• Member must have previously responded to ≥2 intravitreal injections of a vascular endothelial growth factor (VEGF) inhibitor; and
• Member must not have ocular or periocular infections or active intraocular inflammation; and
• Susvimo™ must be prescribed and administered by an ophthalmologist or a physician experienced in vitreoretinal surgery; and
• Prescriber must verify the member will be monitored for endophthalmitis, rhegmatogenous retinal detachment, implant dislocation, vitreous hemorrhage, conjunctival erosion, conjunctival retraction, and conjunctival blebs; and
• A patient-specific, clinically significant reason why the member cannot use ranibizumab intravitreal injection or other VEGF inhibitor injection products (appropriate to disease state) available without prior authorization [i.e., Beovu^® (brolucizumab-dbll), Byooviz™ (ranibizumab-nuna), Cimerli™ (ranibizumab-eqrn), Eylea^® (aflibercept)] must be provided; and
• Susvimo™ will have a quantity limit of one 100mg/0.1mL single-dose vial every 180 days.

Syfovre™ (Pegcetacoplan) Approval Criteria:

• An FDA approved indication for the treatment of geographic atrophy (GA) secondary to dry age-related macular degeneration (AMD); AND
• Member must not have ocular or periocular infections or active intraocular inflammation; AND
• Syfovre™ must be prescribed and administered by an ophthalmologist, or a physician experienced in intravitreal injections; AND
• Prescriber must verify the member will be monitored for endophthalmitis, retinal detachment, increase in intraocular pressure, intraocular inflammation, and neovascular (wet) AMD; AND
• A quantity limit of (1) 0.1mL single-dose vial per eye every 25 to 60 days will apply.

teprotumumab-trbw (Tepezza™) Approval Criteria:  

• An FDA approved indication for the treatment of thyroid eye disease in adult members 18 years of age and older; AND
  • Member must have thyroid blood levels in the normal range or must be undergoing active treatment working toward normal range; AND 
    
• Female members must not be pregnant and must have a negative pregnancy test prior to initiation of therapy; AND
• Female members of reproductive potential must be willing to use effective contraception prior to initiation, during treatment with Tepezza™, and for at least 6 months after the last dose of Tepezza™; AND
• Member must not have had prior surgical treatment for thyroid eye disease; OR
  • A prior authorization request with patient-specific information may be submitted for consideration of Tepezza™ for members who have had prior surgical treatment for thyroid eye disease, including but not limited to patient-specific, clinically significant information regarding the member’s prior surgery and the need for Tepezza™; AND  
• Medical supervision by an ophthalmologist in conjunction with an endocrinologist for the treatment of thyroid eye disease; AND
  • The name of the ophthalmologist and endocrinologist recommending treatment with Tepezza™ must be provided on the prior authorization request; AND  
• Tepezza™ must be administered as an intravenous (IV) infusion at the recommended infusion rate per package labeling, with appropriate pre-medication(s) based on the member’s risk of infusion reactions; AND
• Tepezza™ must be administered by a health care professional. Prior authorization requests must indicate how Tepezza™ will be administered; AND
  • Tepezza™ must be shipped via cold chain supply to the facility where the member is scheduled to receive treatment; OR  
  • Tepezza™ must be shipped via cold chain supply to the member’s home and administered by a home health care provider and the member (or the member’s caregiver) must be trained on the proper storage of Tepezza™; AND  
• The member’s current weight must be provided on the prior authorization request in order to authorize the appropriate amount of drug required according to package labeling; AND
• Approvals will be for a maximum of 8 total infusions.     

Prior Authorization form

Vabysmo™ (Faricimab-svoa Intravitreal Injection) Approval Criteria:

• An FDA approved diagnosis of 1 of the following:
  • Neovascular (wet) age-related macular degeneration (AMD); OR
  • Diabetic macular edema (DME); AND
• Member must be 18 years of age or older; AND
• Member must not have ocular or periocular infections or active intraocular inflammation; AND
• Vabysmo™ must be prescribed and administered by an ophthalmologist or a physician experienced in vitreoretinal injections; AND
• Prescriber must verify the member will be monitored for endophthalmitis, retinal detachment, increase in intraocular pressure, and arterial thromboembolic events; AND
• Female members of reproductive potential must have a negative pregnancy test prior to initiation of therapy and must agree to use effective contraception during treatment and for 3 months after the final dose of Vabysmo™; AND
• A patient-specific, clinically significant reason why the member cannot use VEGF inhibitor injection products (appropriate to the disease state) available without prior authorization [i.e., Beovu^® (brolucizumab-dbll), Byooviz™ (ranibizumab-nuna), Cimerli™ (ranibizumab-eqrn), Eylea^® (aflibercept)] must be provided; AND
• A quantity limit of 0.05mL per 28 days will apply. 

Xiidra® (Lifitegrast) Approval Criteria:

• Member must be 17 years of age or older and have an FDA approved diagnosis of dry eye disease (DED); AND
• Prescriber must verify that environmental factors (e.g. humidity, fans) have been addressed; AND
• Member must have trials with at least 3 over-the-counter (OTC) products for 3 days in the last 30 days that failed to relieve signs and symptoms of dry eyes; AND
• A patient-specific, clinically significant reason why the member cannot use Restasis® (cyclosporine ophthalmic emulsion), which is available without a prior authorization; AND
• A quantity limit of 2 vials per day will apply.

fluocinolone acetonide intravitreal implant (Yutiq™) Approval Criteria: 

• An FDA approved diagnosis of chronic, non-infectious uveitis affecting the posterior segment of the eye; AND  
• Yutiq™ must be administered by an ophthalmologist; AND  
• Prescriber must verify that the member will be monitored for increased intraocular pressure and cataract development; AND 
• A patient-specific, clinically significant reason why the member requires Yutiq™ in place of Ozurdex® must be provided; AND  
• A quantity limit of 1 implant per eye every 36 months will apply.     

Prior Authorization form