CurrentCignaPolicy IP0474

IP0474_Zylet_Ophthalmic_Suspension_Coverage_Policy

Cigna coverage policy governing medical necessity review and prior authorization criteria for Zylet ophthalmic suspension for Individual and Family Plans, including initial approval duration and non-covered uses.

Policy Summary

PayerCigna

PolicyIP0474_Zylet_Ophthalmic_Suspension_Coverage_Policy

Policy CodePolicy IP0474

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateJan 1, 2024

Key ActionCoverage requires meeting one of the medical necessity criteria; receipt of sample product does not satisfy criteria requirements.

SourceLink

POLICY UPDATE CHANGES

No material changes

3Permitted Criteria Options

6 weeksInitial Approval Duration

Coverage Summary

Coverage stance: covered_with_criteria for Zylet (tobramycin 0.3% / loteprednol etabonate 0.5%) for Individual and Family Plans. Coverage requires meeting one of the medical necessity criteria and prior authorization / medical necessity review per provider actions; receipt of sample product does not satisfy criteria requirements. The policy also requires use of preferred products per the member's plan.

Scope summary: Cigna coverage policy governing medical necessity review and prior authorization criteria for Zylet ophthalmic suspension for Individual and Family Plans, including initial approval duration and non-covered uses.

Initial (Medical Necessity) Criteria

Medical Necessity Criteria

The product is considered medically necessary when ONE of the following is met:

ONE of

The individual has had an inadequate response, contraindication, or is intolerant to tobramycin/dexamethasone ophthalmic suspension.
Individual is less than 2 years of age.
Individual is currently receiving Zylet for the treatment of active eye infections.

Medical Necessity Criteria

Provider Actions & Authorization

Prior Authorization

Medical necessity review required

Coverage requires meeting one of the medical necessity criteria; receipt of sample product does not satisfy criteria requirements.

Documentation Required

Clinical justification

Provider must document inadequate response/contraindication/intolerance to tobramycin/dexamethasone ophthalmic suspension or document age <2 years or ongoing treatment with Zylet for active eye infections.

Billing Rule

Authorization duration

Initial approval duration up to 6 weeks; reauthorization not applicable (no continuation beyond initial approval duration).

Background

Background: Zylet is a combination of loteprednol etabonate (a corticosteroid) and tobramycin (an aminoglycoside antibacterial) indicated for steroid-responsive inflammatory ocular conditions for which a corticosteroid is indicated and where superficial bacterial ocular infection or a risk of bacterial ocular infection exists. The policy applies to Individual and Family Plans and requires the use of preferred products per the member's plan.