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 gel 0.5% (Lotemax®)
  • loteprednol ointment 0.5% (Lotemax®)
  • 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®)
  • methazolamide (Neptazane®)
 
 
  • dorzolamide/timolol (Cosopt® PF)
 

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™)
  • travoprost (Travatan® 0.004%)
 
  • latanoprostene bunod (Vyzulta™)
 

Rho Kinase Inibitors

  • netarsudil (Rhopressa®)
 
 
 
 
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
 

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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