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Ocular/Otic

 

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

  • ketotifen (Alaway®, Zaditor OTC®)
  • cromolyn (Crolom®)
  • azelastine (Optivar®)
  • olopatadine (Patanol®)
  • olopatadine hydrochloride (Pazeo™)
  • pemirolast (Alamast®)
  • nedocromil (Alocril®)
  • lodoxamide (Alomide®)
  • loteprednol (Alrex®)
  • bepotastine (Bepreve®)
  • epinastine (Elestat®)
  • emadastine (Emadine®)
  • alcaftadine (Lastacaft®)
  • olopatadine (Pataday®)
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 PA

  • acetic acid (Acetasol®)
  • ciprofloxacin, dexamethasone (Ciprodex®)
  • ciprofloxacin, hydrocortisone (Cipro® HC®)
  • neomycin, colistin, hydrocortisone, thonzonium (Coly-Mycin S®)
  • chloroxylenol/benzocaine/HC (Trioxin®)
  • ciprofloxacin (Cetraxal®)
  • finafloxacin (Xtoro™)
  • neomycin, polymyxin B, hydrocortisone (Cortisporin®, Pediotic®) 
  • ofloxacin (Floxin® Otic)
  • acetic acid/HC (Acetasol® HC)
Ophthalmic NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

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.  

 Prior Authorization form      

Tier 1

Tier 2

 
  • 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™)
Ophthalmic Corticosteroids

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. 

 Prior Authorization form    

Tier 1

Tier 2

 
  • 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®)
Ophthalmic Anti-Infectives

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)

 

Ophthalmic Anti-Infective/Steroid Combinations

Tier 1 products are covered with no authorization necessary

Tier 2 authorization criteria

  • Prescription written by optometrists/ophthalmologists; OR
  • When requested medication is being used for pre/post-operative prophylaxis.

 Prior Authorization form    

Tier 1

Tier 2

 
  • neomycin/polymyxin B/dexamethasone (Maxitrol®) susp & oint
  • sulfacetamide/prednisolone 10%-0.23% solution
  • bacitracin/polymyxin B/neomycin/HC oint
  • gentamicin/prednisolone (Pred-G®) susp & oint
  • neomycin/polymyxin B/HC (Cortisporin®) susp
  • sulfacetamide/prednisolone 10%-0.2% (Blephamide®) susp & oint
  • tobramycin/dexamethasone (Tobradex®) susp & oint
  • tobramycin/loteprednol (Zylet®) susp
Last Modified on Dec 02, 2020
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