Ocular/Otic

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

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

• azelastine (Optivar®)

• pemirolast (Alamast®)
• nedocromil (Alocril®)
• lodoxamide (Alomide®)
• loteprednol (Alrex®)
• bepotastine (Bepreve®)
• epinastine (Elestat®)
• emadastine (Emadine®)
• alcaftadine (Lastacaft®)
• olopatadine (Patanol®)
• olopatadine (Pataday®)
• olopatadine hydrochloride (Pazeo™)

• 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.

• acetic acid (Acetasol®)
• ciprofloxacin, dexamethasone (Ciprodex®)
• ciprofloxacin, hydrocortisone (Cipro® HC®)
• neomycin, polymixin B, hydrocortisone suspension and solution
• neomycin, polymixin B, hydrocortisone, thonzonium (Coly-Mycin S®, Cortisporin®TC)

• ofloxacin (Floxin® Otic)

• acetic acid/HC (Acetasol® HC)

Tier 1 products are covered with no authorization necessary Tier 2 authorization criteria

• Documented trials of all Tier-1 ophthalmic NSAIDs (from different product lines) in the last 30 days that did not yield adequate relief of symptoms or resulted in intolerable adverse effects; OR
• Contraindication to all lower tiered medications; OR
• A unique indication for which the Tier-1 anti-inflammatories lack.

• diclofenac solution 0.1% (Voltaren®)
• flurbiprofen solution 0.03% (Ocufen®)
• ketorolac solution 0.5% (Acular®)

• bromfenac 0.07% (Prolensa™)
• Bromfenac 0.09%
• ketorolac solution (Acuvail®)
• ketorolac solution 0.4% (Acular LS®)
• nepafenac 0.3% (Ilevro™)
• nepafenac 0.1% (Nevanac™)

Tier 1 products are covered with no authorization necessary

Tier 2 authorization criteria

• Documented trials of all Tier-1 ophthalmic corticosteroids (from different product lines) in the last 30 days that did not yield adequate relief of symptoms or resulted in intolerable adverse effects; OR
• Contraindication to all lower tiered medications; OR
• A unique indication for which the Tier-1 anti-inflammatories lack.

• Dexamethason Sodium Phosphate Solution 0.1%
• dexamethason suspension 0.1% (Maxidex™ )
• difluprednate emulsion 0.05% (Durezol®)
• fluorometholone suspension 0.1% (Flarex®, FML Liquifilm®)
• loteprednol suspension 0.5% (Lotemax®)
• prednisolone acetate suspension 1% (Omnipred®)
• prednisolon acetate suspension 0.12% (Pred Mild®)
• Prednisolone Sodium Phosphate Solution 1%
• rimexolone suspension 1% (Vexol®)

• fluorometholone ointment 0.1% (FML S.O.P®)
• fluorometholone suspension 0.25% (FML Forte®)
• loteprednol gel 0.5% (Lotemax®)
• loteprednol ointment 0.5% (Lotemax®)
• prednisolone acetate suspension (Pred Forte®)

Tier 1 products are covered with no authorization necessaryTier 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

• 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)

• latanoprost (Xalatan®)
• travoprost (Travatan® Z)

• bimatoprost (Lumigan®)
• tafluprost (Zioptan®)
• travoprost 0.003% (Izba®)
• travoprost 0.0004% (Travatan®)
• unoprostone (Rescula®)

• dipivefrin (Propine®)

• brimonidine 0.2%
• brinzolamide/brimonidine (Simbrinza™)

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

• brinzolamide (Azopt®)
• dorzolamide/timolol (Cosopt®)
• dorzolamide (Trusopt®)
• acetazolamide (Diamox®)
• methazolamide (Neptazane®)*
• brinzolamide/briminidine tartrate (Simbrinza® 1%, 0.2% Ophth)

*(Indicates Available Oral Products)

• pilocarpine (Isopto Carpine®, Pilopine® HS 0.5%, 1%,2%,4%,6%)

• carbachol (Miostat®)
• 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-B/hydrocortisone (Cortisporin®)
  • neomycin/polymyxin-B/dexamethasone (Maxitrol®)

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.

•  
• gentamicin (Gentak®)
• neomycin/polymyxinB/ gramacidin (AK-spore®)
• ofloxacin (Ocuflox®)
• polymyxinB/trimethoprim (Polytrim®)
• sodium sulfacetamide (Blehp-10, Sodium Sulamyd ®)
• tobramycin (AK-tob ®)

• ciprofloxacin(Ciloxan®)

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

•  
• 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®)