CurrentAvMedPolicy Pub. 100-2

iDose TR (travoprost intracameral implant) prior authorization

This form governs prior authorization and step-edit requirements for coverage of the iDose TR (travoprost intracameral implant, J2508) for AvMed members and specifies clinical criteria, documentation, and limits for prescribers.

Policy Summary

PayerAvMed

PolicyiDose TR (travoprost intracameral implant) prior authorization

Policy CodePolicy Pub. 100-2

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization with prescriber signature and provide documentation verifying failures of required prior therapies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/eyeMaximum implants allowed

6 monthsLength of authorization

18+Minimum age

≥2 agentsProstaglandin step

≥2 classesTwo-class step

Coverage Criteria

Initial Approval Criteria

Covered when ALL of the following are met

Age: Member is 18 years of age or older.>=18 years

Prescriber: Prescribed by, or in consultation with, an Ophthalmologist.

Diagnosis: Member has ONE of the following diagnoses: Open-Angle Glaucoma (OAG) OR Ocular Hypertension (OHT).

Exclusion history: No history of prior corneal or endothelial cell transplants; no active or suspected ocular/periocular infection or corneal endothelial cell dystrophy; intact (not absent or ruptured) posterior lens capsule; no eye/laser surgeries within the past 6 months in the affected eye(s).

Policy Summary

PayerAvMed

PolicyiDose TR (travoprost intracameral implant) prior authorization

Policy CodePolicy Pub. 100-2

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization with prescriber signature and provide documentation verifying failures of required prior therapies.

SourceLink

On This Page

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Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for iDose TR (travoprost intracameral implant) J2508. The prescribing physician must sign and clearly print their name on the request (preprinted stamps not valid). Incomplete, incorrect, or illegible information — including missing documentation such as chart notes, diagnostics, or pharmacy/medical paid claims — can delay or result in denial of authorization.

J2508 (iDose TR travoprost intracameral implant)

Step Therapy

Step Therapy and Verification

Approval requires documentation that the member has had treatment failure, intolerance, or contraindication to two ophthalmic prostaglandin analogs (e.g., bimatoprost, latanoprost, travoprost) and to at least two ophthalmic products from two different pharmacologic classes for OAG or OHT (examples listed). Verification must be via chart notes and/or pharmacy paid claims. Failure, intolerance, or contraindication to Durysta™ must also be documented.

Step therapy requires failure/intolerance/contraindication to TWO ophthalmic prostaglandin analogs (e.g., bimatoprost, latanoprost, travoprost).
AND failure/intolerance/contraindication to at least TWO ophthalmic products from TWO different pharmacologic classes (examples: alpha-agonist, beta-blocker, carbonic anhydrase inhibitor, rho kinase inhibitor).
AND documented failure/intolerance/contraindication to Durysta™ (verification via chart notes or medical claims).
Previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Documentation Required

Required Supporting Documentation and Signature

Provide documentation to support each clinical criterion checked, including chart notes, diagnostics, and pharmacy or medical paid claims. If medication is being provided by a specialty pharmacy, indicate which (Proprium Rx) or if provided in the physician's office. Use of samples to initiate therapy does not meet step edit/preauthorization criteria.

Attach chart notes and diagnostics demonstrating diagnoses (Open-Angle Glaucoma or Ocular Hypertension).
Attach evidence of prior medication trials and outcomes (pharmacy paid claims or chart notes).
Indicate where medication will be provided: Physician's office or Specialty Pharmacy (Proprium Rx).
Ensure prescriber signature and printed name are present on request form.

Denial Risk

Incomplete or Missing Documentation — Risk of Delay or Denial

Incomplete, incorrect, or illegible requests, or missing supporting documentation (e.g., chart notes, diagnostics, pharmacy or medical paid claims) can delay review or lead to denial. For Medicare members, ensure compliance with applicable NCDs/LCDs and reference the Medicare Coverage Database as needed.

Fax completed request (with prescriber signature) to 1-877-535-1391.
For urgent reviews, contact AvMed Pre-Authorization Department to request expedited review.
Medicare members: verify NCD/LCD applicability via CMS Medicare Coverage Database.

OpenPayer

iDose TR (travoprost intracameral implant) prior authorization

Coverage Criteria

Coding

Provider Actions and Requirements

Background

Definitions