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

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®)

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)

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™)

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®)

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

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®) 

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)

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