Glaucoma Prostaglandins
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Defines prior authorization and medical necessity criteria for coverage of ophthalmic prostaglandin products to reduce intraocular pressure in patients with open-angle glaucoma or ocular hypertension for Cigna-administered health benefit plans.
Preferred product criteria were updated to require four preferred products (previously two) for Employer and Individual and Family Plans and added additional preferred product alternatives (e.g., bimatoprost 0.03%, tafluprost 0.0015%).
Rhopressa preferred product requirements for Individual and Family Plans were changed: removed trial of parasympathomimetic, topical/oral carbonic anhydrase inhibitor, and a second prostaglandin analog; added trial of an ophthalmic carbonic anhydrase inhibitor.
Notes with examples of ophthalmic beta-blockers, alpha-adrenergic agonists, and carbonic anhydrase inhibitors were added.
Omlonti (and several generics such as latanoprost, travoprost, tafluprost) were added to the policy as preferred products.
Coverage Criteria
inv-01: FDA-Approved Indications
Ophthalmic prostaglandins are considered medically necessary when ONE of the following criteria is met (1 or 2):
Open-angle includes normal-tension glaucoma.
inv-02: Employer plan product-specific criteria
Employer plan product criteria (examples — each product has specific trial or allergy criteria):
Trials of brand version of a generic count toward requirements per policy.
May require prior authorization.
If patient tried the brand version of a generic equivalent product, that trial counts toward the requirement; trials may require prior authorization.
inv-03: Individual and Family plan criteria
Individual/Family plan criteria include multi-agent trials and class trials for certain products:
Trials of brand version of generics count toward requirement; may require prior authorization.
Examples of agents for each class are provided in policy; combination agents count as a trial of their components.
A combination ophthalmic agent containing the requested drug products would count as a trial of the respective alternatives.
inv-04: Initial and agent-specific prior therapy criteria
Covered when ALL/ONE of the following as specified by agent and plan:
Examples of agents for each class are provided in policy.
Agent-specific variations provided; brand trial of a generic satisfies requirement.
Applies to Vyzulta per policy; trials may require prior authorization.
Prescriber documentation of the reason trials failed or intolerance is required.
Prescription benefit coverage of ophthalmic prostaglandin products for cosmetic conditions is not recommended. Bimatoprost 0.03% (marketed as Latisse for eyelash hypotrichosis) is specifically excluded from this policy and is not included for coverage under the ophthalmic prostaglandin criteria.
Prior Authorization is required for benefit coverage of ophthalmic prostaglandins; however, cosmetic uses such as eyelash growth are not appropriate indications for approval under this prescription benefit policy.
Ophthalmic prostaglandin products used for any purpose other than the covered indications in this policy are considered not medically necessary. Examples include cosmetic conditions such as eyelash growth; this list is not exhaustive and will be updated as new data become available.
Reimbursement is not allowed for services when billed for conditions or diagnoses that are not covered under this Coverage Policy. Providers must submit claims using the most appropriate covered diagnosis and/or procedure code(s) as of the effective date; submissions lacking covered codes will be denied as not covered.
Use of ophthalmic prostaglandins for cosmetic indications (for example, eyelash growth) is not medically necessary and is excluded from coverage under the prescription benefit. Bimatoprost 0.03% marketed as Latisse for eyelash hypotrichosis is not included in this policy.
Coding and Product Lists
| affected codes | Policy references that services must be submitted with covered diagnosis and/or procedure code(s); specific CPT/HCPCS/ICD codes not listed in this part of the document. |
| NDCs and exact codes not specified in this document portion | No explicit CPT/HCPCS/ICD-10/NDC codes are listed in these chunks. |
Provider Actions and Prior Authorization
Prior authorization required
Prior authorization is required for benefit coverage of ophthalmic prostaglandins; approvals for FDA‑approved indications are provided for 1 year when the criteria are met.
PA required for non‑preferred agents when step therapy applies
Submit prior authorization when requesting non‑preferred prostaglandin agents; approval requires documented trials of preferred prostaglandin(s) and required adjunct class trials (beta‑blocker and either an alpha‑agonist or ophthalmic carbonic anhydrase inhibitor) unless there is documented allergy/intolerance or preservative sensitivity.
Step therapy: required prior trials
Many branded products require documented trials of specified generic or bioequivalent prostaglandin agents and, in some cases, trials of other medication classes (e.g., beta‑blockers, alpha‑agonists, or carbonic anhydrase inhibitors) prior to approval per Employer or Individual & Family plan criteria.
Step therapy intensification: four preferred products required
Step therapy was updated to require trials of multiple preferred products (now four preferred products for many agents); providers must document trials of the specified preferred products (examples include latanoprost 0.005%, bimatoprost 0.03%, travoprost 0.004%, tafluprost 0.0015%) before requesting branded agents such as Lumigan, Vyzulta, Zioptan, and others.
Billing and coding must match covered codes and diagnoses
Bill using the most appropriate covered diagnosis and procedure codes as of the effective date; services billed for conditions or diagnoses not covered under this policy will not be reimbursed.
Document prior trials and reasons for failure/intolerance
Include prescriber documentation of prior medication trials (which agent was tried), the reason a trial failed or was not tolerated, or documentation that a bioequivalent generic cannot be used due to inactive‑ingredient or preservative sensitivity (e.g., BAK sensitivity).
Coding/claims mismatch will cause denial
Claims submitted without the covered diagnosis or procedure code(s) required by this Coverage Policy will be denied as not covered.
Prior trials must be documented or coverage may be denied
Coverage may be denied if required prior trials are not documented: at minimum, trials of one ophthalmic prostaglandin, one ophthalmic beta‑blocker, and either one ophthalmic alpha‑adrenergic agonist or one ophthalmic carbonic anhydrase inhibitor are required per plan‑specific criteria.
Background
Ophthalmic prostaglandin products reduce elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension, and thereby reduce the risk of glaucoma progression. Most products are single-entity prostaglandin analogs; Rocklatan is a combination product containing netarsudil (a rho kinase inhibitor) plus latanoprost. Although bimatoprost 0.03% has a marketed cosmetic formulation (Latisse) for eyelash growth, that cosmetic indication is not included or covered by this policy.
Definitions
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