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

  • cromolyn (Crolom®)
  • ketotifen (Alaway®, Zaditor OTC®)
 
  • azelastine (Optivar®)
  • epinastine (Elestat®)
  • olopatadine (Patanol®) 

 

 
  • alcaftadine (Lastacaft®)
  • bepotastine (Bepreve®)
  • cetirizine (Zerviate™)
  • emadastine (Emadine®)
  • lodoxamide (Alomide®)
  • loteprednol (Alrex®)
  • nedocromil (Alocril®)
  • olopatadine (Pataday®)
  • olopatadine hydrochloride (Pazeo™) 

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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.

Special PA Criteria:

Otiprio® (Ciprofloxacin 6% Otic Suspension) Approval Criteria:

  • An FDA approved indication of one of the following:
    • For the treatment of bilateral otitis media with effusion in members undergoing tympanostomy tube placement; OR
    • For the treatment of acute otitis externa due to Pseudomonas aeruginosa (P. aeruginosa) or Staphylococcus aureus (S. aureus); AND
     
  • Member must be 6 months of age or older; AND
  • Otiprio® must be administered by a health care professional; AND
  • A patient-specific, clinically significant reason why appropriate lower tiered otic anti-infective medications cannot be used; AND
  • A quantity limit of 1 vial per treatment course will apply.

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®)

•ciprofloxacin (Cetraxal®)
•ciprofloxacin/fluocinolone (Otovel®)
•finafloxacin (Xtoro™)
•neomycin, polymyxin B, hydrocortisone (Cortisporin®, Pediotic®)
•ofloxacin (Floxin® Otic)

  • acetic acid/HC (Acetasol® HC, VoSol® HC)
  • ciprofloxacin 6% (Otiprio®)
 

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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®)  
  • nepafenac 0.3% (Ilevro™) 
  • bromfenac 0.07% (Prolensa™)
  • bromfenac (BromSite™) 0.075% solution 
  • Bromfenac 0.09%
  • ketorolac solution (Acuvail®)
  • ketorolac solution 0.4% (Acular LS®)
  • nepafenac 0.1% (Nevanac™)

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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%
  • fluorometholone ointment 0.1% (FML S.O.P®)
  • fluorometholone suspension 0.25% (FML Forte®)
  • loteprednol (Inveltys™) 1% susp
  • loteprednol gel 0.5% (Lotemax®)
  • loteprednol ointment 0.5% (Lotemax®)
  • loteprednol (Lotemax® SM) 0.38% gel
  • prednisolone acetate suspension (Pred Forte®)
 
       
Ophthalmic Glaucoma Medications 

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.

Prior Authorization form  

Tier 1

Tier 2

Special PA

Alpha-2 Adrenergic Agonists

  • brimonidine (Alphagan® 0.2%) 
  • brimonidine (Alphagan-P® 0.1%) 
  • brimonidine/timolol (Combigan®) 
  • brinzolamide/brimonidine (Simbrinza®)
 

•apraclonidine (Iopidine®)

  • brimonidine (Alphagan-P® 0.15%)
 

Beta-Blockers

  • brimonidine/timolol (Combigan®)
  • carteolol (Ocupress® 1%)
  • dorzolamide/timolol (Cosopt®)
  • levobunolol (Betagan®)
  • timolol maleate (Istalol®, Timoptic®)
 
  • betaxolol (Betoptic® 0.5%, Betoptic-S®)
 
  • dorzolamide/timolol (Cosopt® PF)
  • timolol maleate (Timoptic Ocudose®, Timoptic-XE®)
 

Carbonic Anhydrase Inhibitors

  • acetazolamide (Diamox®)
  • brinzolamide (Azopt®)
  • brinzolamide/brimonidine (Simbrinza®)
  • dorzolamide (Trusopt®)
  • dorzolamide/timolol (Cosopt®) 
 
 
  • dorzolamide/timolol (Cosopt® PF)
  • methazolamide (Neptazane®)
 

Cholinergic Agonists/Cholinesterase Inhibitors

  • echothiophate iodide (Phospholine Iodide®)
 
  • pilocarpine (Isopto® Carpine®, Pilopine HS®)
 
 

Prostaglandin Analogs 

  • latanoprost (Xalatan®)
  • travoprost (Travatan-Z® 0.004%)
 
  • bimatoprost (Lumigan®)
  • tafluprost (Zioptan™)
 
  • latanoprost (Xelpros™ 0.005%) 
  • latanoprostene bunod (Vyzulta™)
 

Rho Kinase Inibitors

  • netarsudil (Rhopressa®)
  • netarsudil/latanoprost (Rocklatan™)
 
 
 
 
 
 
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)
 

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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
  • tobramycin/dexamethasone 0.3%/0.1% (Tobradex®) susp - Brand Only
 
  • 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®) oint
  • tobramycin/dexamethasone 0.3%/0.05% (Tobradex® ST)
  • tobramycin/loteprednol (Zylet®) susp
 

cenegermin-bkbj (Oxervate™)

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   

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.

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