CurrentAvMedPolicy N/A

Upneeq (oxymetazoline hydrochloride) ophthalmic solution prior authorization

Defines pharmacy prior authorization, initial and reauthorization clinical criteria, and quantity limits for Upneeq (oxymetazoline 0.1% ophthalmic solution) for AvMed members; applies to prescribers submitting authorization requests.

Policy Summary

PayerAvMed

PolicyUpneeq (oxymetazoline hydrochloride) ophthalmic solution prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must sign the prior authorization request and submit chart notes documenting baseline MRD1 (≤2 mm) and patient-reported functional impairment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30quantity limit (per 30 days)

6 moinitial approval

12 moreauthorization

>=18minimum age

Coverage Criteria

inv-01: Initial Therapy

Covered when ALL of the following are met for initial authorization

Initial Authorization

Age: Individual is 18 years of age or older>=18 years
Diagnosis of acquired blepharoptosis confirmed by MRD1 measurement of <=2 mm (please provide chart notes)MRD1 <= 2 mm
provide chart notes
Functional impairment: Documentation of at least ONE of the following patient-reported features of functional impairment from acquired blepharoptosis (please provide chart notes)

Policy Summary

PayerAvMed

PolicyUpneeq (oxymetazoline hydrochloride) ophthalmic solution prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must sign the prior authorization request and submit chart notes documenting baseline MRD1 (≤2 mm) and patient-reported functional impairment.

SourceLink

On This Page

List includes interference with occupational duties/safety, decreased peripheral vision, compensatory chin-up/backward head tilt, difficulty reading, eye discomfort/fatigue/strain

Documentation requirement: All supporting documentation (lab results, diagnostics, and/or chart notes) must be provided or request may be denied

Incomplete requests may be delayed or denied

inv-02: Continuation / Reauthorization

Covered when ALL of the following are met for reauthorization

Reauthorization

Adverse effects attestation: Attestation that the member has not developed any negative side effects from the medication
MRD1 improvement: Documentation of improvement in MRD1 measurement from baseline (please provide chart notes)improvement from baseline
provide chart notes
Symptom improvement: Documentation of improvement of patient-reported features of functional impairment from acquired blepharoptosis (please provide chart notes)
provide chart notes

Documentation requirement: All supporting documentation (lab results, diagnostics, and/or chart notes) must be provided or request may be denied

Incomplete requests may be delayed or denied

Upneeq will NOT be approved for members with a diagnosis of dermatochalasis (excessive eyelid tissue). This exclusion is explicit on the authorization form and must be considered when evaluating prior authorization requests.

No other specific conditions are listed as not medically necessary beyond the exclusion for dermatochalasis. The form does not enumerate additional explicit NMN scenarios.

Coding and Diagnostic Entry

Diagnosis code entryICD-10

ICD code — space provided on form; specific ICD-10 codes not listed in document

MRD1 measurement — threshold

MRD1 threshold≤2 mm

Measurement purposeUsed to confirm diagnosis of acquired blepharoptosis (provide chart notes)

Role in initial authorizationRequired for initial approval (one of the ALL criteria)

Role in reauthorizationDocumentation of improvement in MRD1 from baseline required for continued coverage

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required — Prior authorization is required for Upneeq (oxymetazoline ophthalmic solution 0.1%). The prescribing physician must sign and clearly print their name on the prior authorization request form (preprinted stamps are not valid). Fax completed requests to 1-305-671-0200. Incomplete, incorrect, or illegible information (including missing documentation/chart notes) can delay the authorization process.

Drug: Upneeq (oxymetazoline hydrochloride) ophthalmic solution 0.1%
Fax: 1-305-671-0200
Prescriber signature required (no preprinted stamps)

Step Therapy

Samples and Prior Therapy Verification

Samples may not be used to satisfy preauthorization or step-edit requirements. The use of samples to initiate therapy does not meet step edit/preauthorization criteria. Previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Use of samples does not meet criteria
Previous therapies verified via pharmacy claims or chart notes

Documentation Required

Required Clinical Documentation

Required clinical documentation must be provided with the request. For initial authorization, provide chart notes documenting MRD1 measurement ≤2 mm at baseline, and documentation of at least one patient-reported functional impairment attributable to acquired blepharoptosis (examples: interference with occupational duties/safety, decreased peripheral vision, compensatory chin-up/head tilt, difficulty reading, eye discomfort/fatigue/strain). For reauthorization, provide chart notes documenting improvement in MRD1 from baseline and improvement in patient-reported functional impairment, and attestation of no negative side effects.

Initial: age ≥18, diagnosis of acquired blepharoptosis with MRD1 ≤2 mm, ≥1 patient-reported functional impairment (chart notes)
Reauthorization: documentation of MRD1 improvement from baseline, documentation of improved functional impairment, attestation of no adverse effects

Denial Risk

Incomplete Request Risks Denial

Incomplete requests risk denial or delay — authorization may be delayed or denied if member/prescriber information, drug information, dosing, diagnosis, MRD1 measurements, chart notes, or other required documentation are missing, incorrect, or illegible.

Ensure member name, AvMed ID, DOB, prescriber name, DEA or NPI, office contact, phone and fax are provided
Provide drug form/strength, dosing schedule, length of therapy, diagnosis, ICD code (if applicable), weight, date, and required chart notes

Background

Acquired blepharoptosis (ptosis) can cause functional visual impairment that is assessed using the Margin Reflex Distance 1 (MRD1) measurement and by documenting patient-reported symptoms. The authorization form requires an MRD1 of ≤2 mm at baseline and chart notes describing at least one functional impairment (for example decreased peripheral vision, difficulty reading, compensatory head posture, interference with occupational duties/safety, or eye discomfort/fatigue). Upneeq (oxymetazoline 0.1%) is intended to treat symptoms of acquired blepharoptosis and approval decisions are based on those clinical findings.

Definitions

MRD1 (Margin Reflex Distance 1)

DefinitionMargin Reflex Distance 1 (MRD1) — measurement used to assess degree of upper eyelid droop

Baseline requirementApproval requires MRD1 ≤ 2 mm at baseline (chart notes must be provided)

Reauthorization requirementReauthorization requires documentation of improvement in MRD1 measurement from baseline (chart notes must be provided)

Clinical contextMRD1 is used to confirm acquired blepharoptosis as part of clinical criteria for Upneeq

Initial Therapy Criteria

inv-13: Initial therapy

Initial authorization criteria

Initial

Age: Individual is 18 years of age or older>=18 years
MRD1: Diagnosis of acquired blepharoptosis confirmed by MRD1 measurement of <=2 mm (please provide chart notes)<=2 mm
provide chart notes
Functional impairment: At least one documented patient-reported feature of functional impairment (interference with occupational duties/safety, decreased peripheral vision, compensatory chin-up/backward head tilt, difficulty reading, eye discomfort/fatigue/strain)
provide chart notes

Quantity limit: 30 single-dose vials per 30 days30 per 30 days

Continuation / Reauthorization Criteria

inv-14: Reauthorization

Reauthorization requirements for continued coverage

Reauthorization

No adverse effects: Attestation that the member has not developed any negative side effects from the medication
MRD1 improvement: Documentation of improvement in MRD1 measurement from baseline (please provide chart notes)improvement from baseline
provide chart notes
Symptom improvement: Documentation of improvement of patient-reported functional impairment
provide chart notes

Documentation requirement: All supporting documentation (lab results, diagnostics, and/or chart notes) must be provided or request may be denied

Incomplete requests may be delayed or denied

Step Therapy and Samples

Requirement	Details
Use of samples to initiate therapy
Use of samples to initiate therapy does not meet step-edit/preauthorization criteria.

Quantity Limits

Quantity limit

ProductUpneeq (oxymetazoline 0.1% ophthalmic solution)

Quantity limit30 single-dose vials per 30 days

Unitsingle-dose vials

Source noteQuantity limit listed on authorization form and applies to prior authorization

Site of Care

Note

Standard pharmacy dispensing prior authorization (site of care)

Site of care is not specified in the policy; standard pharmacy dispensing prior authorization procedures apply for home use.