CurrentBlue Cross Blue Shield - MassachusettsPolicy 346

Ophthalmic prostaglandin step therapy

Defines step therapy, prior authorization, and coverage rules for ophthalmic prostaglandin medications for BCBSMA commercial members; applies to providers requesting coverage under the plan's pharmacy or medical benefits.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyOphthalmic prostaglandin step therapy

Policy CodePolicy 346

Change TypeNo material change

Effective DateJan 1, 2012

Next Review Date

Key ActionObtain prior authorization and document trials of formulary alternatives (names, strengths and dates) when requesting step-designated or non-formulary ophthalmic prostaglandins.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

130 dayslook-back period to establish prior use

Step 1–3step therapy tiers described

Prior Authorization requiredadministrative step noted

Commercialpopulation covered

Coverage Criteria for Ophthalmic Prostaglandins

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.

Step therapy coverage criteria

Covered when step therapy requirements are met:

Step requirement general: Member must meet the step requirement for the requested ophthalmic prostaglandin as specified by formulary tiering (Step 1, Step 2, Step 3).

See specific product mapping in summary

Prior use for Step 2 products: Coverage of certain Step 2 branded products requires prior use of ONE step medication OR history of prior use of any Step 2 medication within the previous 130 days.130 days

Examples: Lumigan (bimatoprost), Travatan Z (travoprost), Xalatan (latanoprost) per product mapping

Prior use for Step 3 or non-covered products: For products designated NFNC or Step 3, the member must have prior use of TWO Step 2 medications OR history of use of a Step 3 medication within the previous 130 days.130 days

Applies to Rocklatan, Xelpros, Vyzulta, Zioptan as indicated

Non-covered medication requirement: When a product is non-covered (NFNC), the member must have had prior treatment failure with, or a contraindication to, at least two covered formulary alternatives when available; exceptions require individual consideration.

See individual consideration section for exception process

Products designated NFNC (Non‑Formulary Non‑Covered) are excluded from coverage unless the member has met the required prior failure criteria or an approved individual exception is granted. For NFNC medications, the policy requires documentation that the member has had a prior treatment failure with, or a contraindication to, at least two covered formulary alternatives when such alternatives are available.

Products designated as NFNC will not be covered in the absence of documentation showing the member has met the step therapy prior‑use requirements or an approved individual consideration. Specifically, coverage for NFNC or higher‑step products requires prior treatment failure with, or contraindication to, the required number of lower‑step formulary alternatives (for some products this is two alternatives) and, where applicable, evidence of prior use within the previous 130 days.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Requirement

Prior Authorization Required: Providers must submit prior authorization requests for step-designated ophthalmic prostaglandins before coverage will be approved. Requests may be submitted by phone, fax, or mail to Pharmacy Operations.

Submission routes: Phone, Fax, Mail (use Formulary Exception / Prior Authorization form)
Policy applies to BCBSMA Commercial plans (HMO, POS, PPO), MEDEX with Rx, Managed Major Medical with Custom BCBSMA Formulary, Comprehensive Managed Major Medical, Managed Blue for Seniors

Step Therapy

Step Therapy Requirement

Step therapy is enforced for specified ophthalmic prostaglandins. Members must trial lower-step formulary prostaglandins (step 1 and step 2 agents as defined by the formulary) prior to coverage of step-designated products. Non-formulary/non-covered agents designated ST/NFNC require additional prior use criteria.

Examples: Xalatan, Travatan Z, Lumigan designated as step therapy (ST) requiring prior use of one step medication or prior use of a step 2 agent within the previous 130 days
Step 3/NFNC products (e.g., Rocklatan, Xelpros, Vyzulta, Zioptan where applicable) require prior use of two step 2 medications or history of a step 3 medication within previous 130 days

Documentation Required

Provider Documentation Required

Provider documentation must be submitted when prescription claim history does not demonstrate required prior use or when the member cannot trial formulary alternatives. Documentation must list agents tried, strengths, dates (if available), and detailed clinical rationale for failure or contraindication.

Include name and strength of each formulary alternative tried and failed
Provide dates of trials and specific details of treatment failure (e.g., adverse events, lack of efficacy)
If not tried, provide clinical rationale (contraindication, intolerance, other medical reason) supporting why alternatives cannot be used

Denial Risk

Non‑Covered Medication Denial Risk

Denial Risk for Non‑Formulary/Non‑Covered Agents: Coverage of NFNC products may be denied unless the member has documented prior failures or contraindications to the required number of covered formulary alternatives. Higher non‑preferred cost share may apply if an exception is granted.

NFNC coverage requires documented failure of or contraindication to two covered formulary alternatives (when available)
If prescription claims do not demonstrate required prior use within previous 130 days, submit provider documentation as described above
Approved exceptions may still result in higher non‑preferred cost share for the member

Background

Ophthalmic prostaglandins (examples include latanoprost, bimatoprost, travoprost, tafluprost) are topical agents commonly used to lower intraocular pressure in patients with glaucoma or ocular hypertension. This policy groups these agents into step therapy tiers to encourage use of formulary‑preferred, lower‑step alternatives before authorizing coverage for branded, higher‑step, or non‑formulary/ non‑covered products. Certain branded agents (for example, Lumigan, Travatan Z, Xalatan) require prior use of one step medication or evidence of step‑2 use within the previous 130 days, while some products designated NFNC require prior use of two step‑2 medications or history of step‑3 medication use within the previous 130 days.

Definitions

Step Therapy (ST) definition (inv-10)

DefinitionStep Therapy (ST) is a formulary management process requiring trial and failure of specified lower-step medications before coverage of designated step medications

Application in this policyMembers must trial lower-step formulary ophthalmic prostaglandins (Step 1 or Step 2) before coverage of step-designated products; specific product mappings define step tiering

Documentation requirementProviders must document names/strengths of formulary alternatives tried and failed; additional documentation required if claim data do not establish prior use

NFNC (Non-Formulary Non-Covered) definition (inv-11)

DefinitionNFNC (Non-Formulary Non-Covered) = Products designated non-formulary and not covered unless required prior failures are met or an exception is approved

Coverage conditionNFNC products are excluded from coverage unless the member has met prior failure requirements or receives individual consideration/exception

Prior failure expectationRequests for NFNC medications generally require prior failure of two covered formulary alternatives when available (per product-specific rules)

OpenPayer

Ophthalmic prostaglandin step therapy

Coverage Criteria for Ophthalmic Prostaglandins

Coding and Look-back

Provider Actions, Prior Authorization, and Documentation

Background

Definitions