CurrentBluecross IdahoPolicy MP 5.01.680

Travoprost Intracameral Implant

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This policy governs medical necessity and coverage criteria for surgical placement and readministration of the iDose TR travoprost intracameral implant to reduce intraocular pressure in adults with open-angle glaucoma or ocular hypertension. It also identifies contraindications, investigational uses, administration limits, and relevant benefit-plan limitations.

Policy Summary

PayerBluecross Idaho

PolicyTravoprost Intracameral Implant

Policy CodePolicy N/A

Change TypeNew policy adoption

Effective DateNov 1, 2026

Last ReviewJul 30, 2026

Next Review DateN/A

Key ActionBefore surgical placement, verify age 18 or older, qualifying glaucoma or ocular hypertension, required prior topical therapy, and baseline corneal endothelial evaluation.

SourceLink

POLICY UPDATE CHANGES

Blue Cross of Idaho adopted this policy as a new pharmacy policy effective November 1, 2026.

18+Minimum patient age

1Required topical prostaglandins

2Required agents from different classes

75 mcgTravoprost dose per implant

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CurrentBluecross IdahoPolicy MP 5.01.680

Travoprost Intracameral Implant

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Get alerted when Policy MP 5.01.680 changes without checking for updates manually.

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Policy Summary

PayerBluecross Idaho

PolicyTravoprost Intracameral Implant

Policy CodePolicy N/A

Change TypeNew policy adoption

Effective DateNov 1, 2026

Last ReviewJul 30, 2026

Next Review DateN/A

Key ActionBefore surgical placement, verify age 18 or older, qualifying glaucoma or ocular hypertension, required prior topical therapy, and baseline corneal endothelial evaluation.

SourceLink

POLICY UPDATE CHANGES

Blue Cross of Idaho adopted this policy as a new pharmacy policy effective November 1, 2026.

18+Minimum patient age

1Required topical prostaglandins

2Required agents from different classes

75 mcgTravoprost dose per implant

Once annuallyMaximum readministration frequency

4Coding systems represented

Medical Necessity and Coverage Criteria

Travoprost Intracameral Implant Medical Necessity

Surgical placement of a travoprost intracameral implant (e.g., iDose TR) may be considered medically necessary when ALL applicable criteria are met:

ALL of the following

The individual is 18 years of age or older.
The individual has been diagnosed with open-angle glaucoma (OAG) or ocular hypertension (OHT).
The individual has had inadequate treatment response to, is intolerant of, or has a contraindication to at least ONE (1) topical ophthalmic prostaglandin (e.g., bimatoprost, latanoprost, travoprost).
The individual has had inadequate treatment response to, is intolerant of, or has a contraindication to at least TWO (2) topical ophthalmic agents from different medication classes: alpha-adrenergic agonists (e.g., brimonidine, apraclonidine); beta-blockers (e.g., timolol, betaxolol, carteolol, levobunolol, metipranolol); or carbonic anhydrase inhibitors (e.g., brinzolamide, dorzolamide).
iDose TR is administered only to the affected eye.
The dose does not exceed one implant (75 mcg travoprost) per affected eye.

Readministration and Endothelial Monitoring

Readministration may be considered only when ALL applicable monitoring and timing requirements are met:

ALL of the following

The corneal endothelium is evaluated by specular microscopy, and a pre-implantation baseline corneal endothelial cell density is established before the initial administration of iDose TR and before any readministration.
Readministration of iDose TR is not performed more than once per year.<= 1 readministration per year
Readministration is performed with caution in eyes with 10% or greater loss in central corneal endothelial cell density from the pre-administration baseline.>= 10% endothelial cell density loss
Caution is required when central corneal endothelial cell density loss reaches or exceeds 10% from baseline.

Travoprost intracameral implant is contraindicated in individuals with ocular or periocular infections; corneal endothelial dystrophy (e.g., Fuchs' dystrophy or corneal guttatae); prior corneal transplantation or endothelial cell transplantation (e.g., Descemet's Stripping Automated Endothelial Keratoplasty [DSAEK]); or hypersensitivity to travoprost or any other product component.

The iDose TR is magnetic resonance imaging (MRI) conditional. Patients who require an MRI should inform their healthcare provider that they have an iDose TR implanted in their eye. The safety and effectiveness of iDose TR have not been established in pediatric patients, and safety has not been established for pregnant individuals or those who are breastfeeding.

Concurrent use of iDose TR with Durysta (bimatoprost intracameral implant) is not medically necessary.

Requests for travoprost intracameral implant (iDose TR) are not medically necessary when the previously treated eye is retreated within the past 12 months, when the individual is receiving concurrent Durysta, or when the coverage criteria are not met. All other indications for travoprost intracameral implant (iDose TR) are considered investigational.

Coding Reference

CPTCPT

0660T	Implantation of anterior segment intraocular nonbiodegradable drug-eluting system, internal approach
0661T	Removal and reimplantation of anterior segment intraocular nonbiodegradable drug-eluting implant

HCPCSHCPCS

J7355

Injection, travoprost, intracameral implant, 1 microgram

ICD-10-CMICD-10

H40.051	Ocular hypertension
H40.059	Ocular hypertension
H40.10X0	Open-angle glaucoma

ICD-10-PCSICD-10

H40.159

Authorization and Documentation Requirements

Prior Authorization

Initial Authorization Criteria

Authorize initial surgical placement only when the individual meets the age and diagnosis requirements for iDose TR and all other criteria in this section are documented.

Individual is 18 years of age or older.
Individual has a diagnosis of open-angle glaucoma (OAG) or ocular hypertension (OHT).
Surgical placement is requested for the affected eye and is supported by the required topical-treatment history and baseline endothelial evaluation.

Prior Authorization

Readministration Authorization

Authorize readministration only when at least 12 months have elapsed since the prior implant in the treated eye and the required pre-administration endothelial evaluation has been completed.

Readministration must not occur more than once per year; retreatment within the preceding 12 months is not medically necessary.

Clinical Background

Glaucoma is an optic neuropathy caused by progressive loss of retinal ganglion cell axons and can lead to irreversible blindness if untreated. Lowering intraocular pressure may delay or prevent progression to glaucoma in patients with ocular hypertension. iDose TR is a 75-mcg travoprost prostaglandin analog implant administered intracamerally to reduce intraocular pressure in adults with open-angle glaucoma or ocular hypertension.

Clinical Definitions

Open-angle glaucoma (OAG)

DefinitionA group of glaucomatous disorders in which the drainage angle remains open.

Optic nerve effectOptic nerve damage may progress, including progressive loss of retinal ganglion cell axons.

Common associationOAG is commonly associated with elevated or inadequately controlled intraocular pressure.

Ocular hypertension (OHT)

DefinitionElevated intraocular pressure without the optic nerve damage characteristic of glaucoma.

Distinguishing featureUnlike glaucoma, ocular hypertension does not include characteristic optic nerve damage.

Policy Summary

PayerBluecross Idaho

PolicyTravoprost Intracameral Implant

Policy CodePolicy N/A

Change TypeNew policy adoption

Effective DateNov 1, 2026

Last ReviewJul 30, 2026

Next Review DateN/A

Key ActionBefore surgical placement, verify age 18 or older, qualifying glaucoma or ocular hypertension, required prior topical therapy, and baseline corneal endothelial evaluation.

SourceLink

On This Page

Obtain specular microscopy and establish the pre-readministration baseline corneal endothelial cell density before treatment.

Use caution when central corneal endothelial cell density has decreased by 10% or more from the pre-administration baseline.

Step Therapy

Required Topical Therapy History

Document inadequate response, intolerance, or contraindication to the required topical glaucoma therapies before requesting initial surgical placement.

At least one topical ophthalmic prostaglandin must have been tried or be contraindicated (e.g., bimatoprost, latanoprost, or travoprost).
At least two topical ophthalmic agents from different medication classes must have been tried or be contraindicated.
Eligible classes include alpha-adrenergic agonists, beta-blockers, and carbonic anhydrase inhibitors; document the agent, treatment outcome, intolerance, or contraindication.

Documentation Required

Baseline Endothelial Evaluation

Complete and retain a baseline corneal endothelial evaluation before initial administration and before every readministration of iDose TR.

Perform specular microscopy.
Establish and document the pre-implantation baseline corneal endothelial cell density.
For readministration, compare the current evaluation with the applicable pre-administration baseline and use caution with a 10% or greater loss in central endothelial cell density.

Documentation Required

Clinical Eligibility Documentation

The clinical record must establish each eligibility element supporting medical necessity for travoprost intracameral implant.

Document that the individual is 18 years of age or older and has OAG or OHT.
Document inadequate response, intolerance, or contraindication to at least one topical ophthalmic prostaglandin and at least two topical ophthalmic agents from different classes.
Document the affected eye, specular microscopy findings, baseline endothelial cell density, requested dose, and treatment or readministration interval.
For readministration, document the date of the prior implant and the required pre-administration endothelial assessment.

Denial Risk

Noncovered or Investigational Use

Flag requests that do not satisfy the medical-necessity criteria or that involve prohibited concurrent or early retreatment use.

Retreatment of a previously treated eye within the past 12 months is not medically necessary.
Concurrent use of iDose TR with Durysta (bimatoprost intracameral implant) is not medically necessary.
Requests that do not meet the stated criteria are not medically necessary; all other indications are considered investigational.

Denial Risk

Contraindications and Safety Screening

Screen for contraindications and safety limitations before authorization or administration of iDose TR.

Do not administer with ocular or periocular infection.
Do not administer with corneal endothelial dystrophy, including Fuchs' dystrophy or corneal guttatae.
Do not administer with prior corneal transplantation or endothelial cell transplantation, including DSAEK.
Flag hypersensitivity to travoprost or any product component.
Safety and effectiveness have not been established in pediatric patients; safety has not been established for pregnant or breastfeeding individuals.
iDose TR is MRI conditional; instruct patients to inform healthcare providers about the implant before MRI.

Billing Rule

Dose and Frequency Limits

Enforce the affected-eye, dose, and frequency limits for every administration.

Administer iDose TR only to the affected eye.
Do not exceed one 75-mcg travoprost implant per affected eye.
Readministration must not occur more than once per year.

Clinical significance

Lowering intraocular pressure may delay or prevent progression to glaucoma.

Intraocular pressure (IOP)

DefinitionThe fluid pressure within the eye.

RegulationIntraocular pressure is maintained by production and outflow of aqueous humor.

Normal rangeNormal intraocular pressure is 10 to 21 mm Hg.