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

• 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™)

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

•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®)

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™)

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®)

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®)

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
• 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