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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®)
 

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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.

    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)

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

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Ophthalmic Glaucoma Medications Beta-Blockers Prostaglandin Analogs Alpha-2 Adrenergic Agonists Carbonic Anhydrase Inhibitors Cholinergic Agonists/Cholinesterase Inhibitors

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
  • Prior Authorization form
 

Tier 1

Tier 2

  • brimonidine/timolol (Combigan®)
  • carteolol (Ocupress®)
  • dorzolamide/timolol (Cosopt®)
  • levobunolol (Betagan®)
  • metipranolol (OptiPranolol®)  
  • timolol maleate (Timoptic® 0.5% dropperette)
  • betaxolol (Betoptic® 0.5%)
  • betaxolol (Betoptic® S)
  • dorzolamide/timolol (Cosopt® PF)
  • timolol maleate (Timoptic® Ocudose)
  • timolol maleate ophthalmic gel-forming sol (Timoptic-XE®)
  • timolol maleate ophthalmic sol (Betimol®)  

Tier 1

Tier 2

  • latanoprost (Xalatan®)
  • travoprost (Travatan® Z)  
  • bimatoprost (Lumigan®)
  • tafluprost (Zioptan®)
  • travoprost 0.0004% (Travatan®)  

Adrenergic Agonists 

Tier 1 Tier 2
   

Tier 1

Tier 2

  • brimonidine 0.2%
  • brimonidine (Alphagan® P 0.1%)
  • brimonidine/timolol (Combigan®)
  • brinzolamide/brimonidine (Simbrinza™)
 
  • apraclonidine (Lopidine® 1%)
  • brimonidine (Alphagan® P 0.15%)
     

Tier 1

Tier 2

  • acetazolamide (Diamox®)
  • brinzolamide (Azopt®)
  • brinzolamide/briminidine tartrate (Simbrinza® 1%, 0.2% Ophth)
  • dorzolamide (Trusopt®)
  • dorzolamide/timolol (Cosopt®)
  • methazolamide (Neptazane®)

(Indicates Available Oral Products)

  • dorzolamide/timolol (Cosopt® PF)

Tier 1

Tier 2

  • pilocarpine (Isopto Carpine®, Pilopine® HS 0.5%, 1%,2%,4%,6%)
 
  • carbachol (Miostat®)
  • echothiophate iodide (Phospholine lodide®)

 

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Ophthalmic Anti-Infectives Ophthalmic Antibiotics: Liquids Ophthalmic Antibiotics: Ointments

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)
 

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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
  • 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

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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Source: http://www.okhca.org/providers.aspx?id=12129


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