CurrentAvMedPolicy N/A

Pharmacy prior authorization for ophthalmic antihistamine/ophthalmic allergy agents

Form and clinical criteria governing prior authorization and step-edit requirements for specified ophthalmic antihistamine and allergy eye drops for AvMed members; applies to prescribers requesting coverage for listed agents.

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization for ophthalmic antihistamine/ophthalmic allergy agents

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must submit a completed prior authorization form with required clinical documentation and signatures via fax to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3required prior trial failures for Alocril, bepotastine, Zerviate

1required prior trial failure for Alomide

7alternative topical agents listed

fax 1-305-671-0200submission fax

Coverage Criteria for Ophthalmic Antihistamine and Allergy Agents

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization for ophthalmic antihistamine/ophthalmic allergy agents

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must submit a completed prior authorization form with required clinical documentation and signatures via fax to 1-305-671-0200.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial therapy requirements (Alocril, Bepreve, Zerviate)

For Alocril, bepotastine, and Zerviate

Required prior trials: Documented trial and failure of three listed alternative topical ophthalmic agents3

Alternatives: ketotifen 0.025%, azelastine 0.05%, cromolyn sodium 4%, epinastine 0.05%, olopatadine 0.1%, olopatadine 0.2%. Trials will be verified through paid pharmacy claims or chart notes.

Step Therapy Requirements

Prior Authorization

Prior authorization submission

Step therapy requires prior authorization submission. Submit a completed prior authorization request form including the requested drug name, drug form/strength, dosing schedule, length of therapy, diagnosis and ICD-10 code (if applicable), patient weight and date weight obtained (if relevant), and treating provider information. Authorization may be delayed if the submission is incomplete.

Documentation Required

Required supporting documentation

Supporting documentation must include objective evidence of prior therapies tried and failed. For ocular antihistamines (Alocril, bepotastine, Zerviate), provide documentation of trial and failure of THREE of the following (trials will be verified via paid pharmacy claims or chart notes): ketotifen 0.025% ophthalmic solution; azelastine 0.05% ophthalmic solution; cromolyn sodium 4% ophthalmic solution; epinastine 0.05% ophthalmic solution; olopatadine 0.1% ophthalmic solution; olopatadine 0.2% ophthalmic solution. For Alomide, provide documentation of trial and failure of cromolyn sodium 4% ophthalmic solution. Include chart notes or pharmacy claims with dates and duration of therapy.

Denial Risk

Denial risk if prior therapy not documented

Use of free samples to start therapy does not satisfy step-therapy or preauthorization requirements. Failure to document required prior therapy (e.g., no paid pharmacy claims or chart notes) may result in denial. Not all drugs are covered under every plan; if the drug is non-formulary, medical necessity documentation will be required.

Provider Actions and Submission Requirements

Prior Authorization

Submit prior authorization form via fax

Prior authorization is required for the listed ophthalmic antihistamine/ophthalmic allergy drugs. The prescriber must submit the completed prior authorization/step-edit request form with the required clinical criteria and signatures via fax to 1-305-671-0200.

Documentation Required

Provide all supporting documentation

Provide supporting documentation for each criterion checked on the form; all documentation, including lab results, diagnostics, chart notes, and pharmacy paid claims, must be supplied to support the request.

Prior trials will be verified through paid pharmacy claims or chart notes
Include lab results, diagnostics, and relevant chart documentation as applicable

Documentation Required

Prescriber signature required (no stamps)

The prescribing physician must sign and clearly print their name on the prior authorization request; preprinted stamps are not valid.

Denial Risk

Incomplete or illegible submissions can delay or deny auth

Authorization may be delayed or the request may be denied if information provided is incomplete, incorrect, or illegible.

Ensure member and prescriber information, dosing, diagnosis, and contact details are complete and legible

Definitions

PHARMACY PRIOR AUTHORIZATION/STEP-EDIT REQUEST

Form namePHARMACY PRIOR AUTHORIZATION/STEP-EDIT REQUEST

PurposePrior authorization/step-edit request form for ophthalmic antihistamine/ophthalmic allergy agents

Signature requirementPrescribing physician must sign and clearly print name on the request (preprinted stamps not valid)

Submission methodFax completed form to 1-305-671-0200

Drugs listed on formAlocril (nedocromil 2%), Alomide (lodoxamide 0.1%), Bepreve (bepotastine 1.5%), Zerviate (cetirizine)

Background

Ophthalmic antihistamines and mast cell stabilizers are topical agents used to manage allergic conjunctivitis and other ocular allergy symptoms. The policy requires documented trials of alternative topical agents before approving certain branded or non‑preferred products; for example, approval of Alomide requires a documented trial and failure of cromolyn sodium 4% ophthalmic solution, with trials verified by paid pharmacy claims or chart notes.