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.
Durysta™ (Bimatoprost Implant) Approval Criteria:
- An FDA approved indication to reduce intraocular pressure (IOP) in members with open-angle glaucoma (OAG) or ocular hypertension (OHT); and
- Member must be 18 years of age or older; and
- Durysta™ must be prescribed by, or in consultation with, an ophthalmologist; and
- A patient-specific, clinically significant reason why the member requires Durysta™ and cannot utilize ophthalmic preparations, such as solution or suspension, to treat OAG or OHT must be provided; and
- The affected eye(s) has not received prior treatment with Durysta™; and
- The member has no contraindications to Durysta™; and
- A quantity limit of (1) Durysta™ 10mcg implant per eye per lifetime will apply.
iDose® TR (Travoprost Intracameral Implant) Approval Criteria:
- An FDA approved indication to reduce intraocular pressure (IOP) in members with open-angle glaucoma (OAG) or ocular hypertension (OHT); and
- Member must be 18 years of age or older; and
- iDose® TR must be prescribed by, or in consultation with, an ophthalmologist; and
- A patient-specific, clinically significant reason why the member requires iDose® TR and cannot utilize ophthalmic preparations, such as solution or suspension, to treat OAG or OHT must be provided; and
- A patient-specific, clinically significant reason why the member cannot use Durysta® (bimatoprost intracameral implant) must be provided; and
- The affected eye has not received prior treatment with iDose® TR; and
- Member has no contraindications to iDose® TR; and
- A quantity limit of (1) iDose® TR 75mcg implant per eye per lifetime will apply.
Prior Authorization form
Glaucoma Medications*
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Tier 1
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Tier 2
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Special PA
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Alpha-2 Adrenergic Agonists
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- brimonidine (Alphagan® 0.2%)
- brimonidine (Alphagan-P® 0.1%) - Brand Preferred
- brimonidine/timolol (Combigan® 0.2%/0.5%) – Brand Preferred
- brinzolamide/brimonidine (Simbrinza® 0.2%/1%)
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•apraclonidine (Iopidine® 0.5%, 1%)
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- brimonidine (Alphagan-P® 0.15%)
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Beta-Blockers
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- betaxolol (Betoptic-S® 0.25%)
- brimonidine/timolol (Combigan® 0.2%/0.5%) – Brand Preferred
- carteolol (Ocupress® 1%)
- dorzolamide/timolol (Cosopt® 22.3/6.8mg/mL)
- levobunolol (Betagan® 0.25%, 0.5%)
- timolol maleate (Timoptic® 0.25%, 0.5%)
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- betaxolol (Betoptic® 0.5%)
- dorzolamide/timolol (Cosopt® PF 2%/0.5%)
- timolol (Betimol® 0.25%, 0.5%)
- timolol maleate (Timoptic-XE® 0.25%, 0.5%)
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- timolol maleate (Istalol® 0.5%)
- timolol maleate (Timoptic Ocudose® 0.25%, 0.5%)
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Carbonic Anhydrase Inhibitors
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- acetazolamide (Diamox® 500mg caps; 125mg, 250mg tabs)+
- brinzolamide (Azopt® 1%) – Brand Preferred
- brinzolamide/brimonidine (Simbrinza® 0.2%/1%)
- dorzolamide (Trusopt® 2%)
- dorzolamide/timolol (Cosopt® 22.3/6.8mg/mL)
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- dorzolamide/timolol (Cosopt® PF 2%/0.5%)
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- methazolamide (Neptazane® 25mg, 50mg tabs)+
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Cholinergic Agonists/Cholinesterase Inhibitors
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- echothiophate iodide (Phospholine Iodide® 0.125%)
- pilocarpine (Isopto® Carpine 1%, 2%, 4%)
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Prostaglandin Analogs
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- bimatoprost (Lumigan® 0.01%)
- latanoprost (Xalatan® 0.005%)
- netarsudil/latanoprost (Rocklatan®)
- tafluprost (Zioptan® 0.0015%) - Brand Preferred
- travoprost (Travatan-Z® 0.004%) - Brand Preferred
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- bimatoprost (Lumigan® 0.03%)
- latanoprost (Xelpros™ 0.005%)
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- latanoprost (Iyuzeh™ 0.005%)
- latanoprostene bunod (Vyzulta® 0.024%)
- omidenepag isopropyl (Omlonti® 0.002%)
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Rho Kinase Inibitors
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- netarsudil (Rhopressa® 0.02%)
- netarsudil/latanoprost (Rocklatan®)
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