CurrentCignaPolicy N/A

iDose TR (travoprost implant) prior authorization / patient information

This form governs prior authorization requests for the iDose TR travoprost intracameral implant for Cigna members and collects required patient, prescriber, and clinical information needed to determine coverage.

Policy Summary

PayerCigna

PolicyiDose TR (travoprost implant) prior authorization / patient information

Policy CodePolicy N/A

Change TypeAdministrative - no material clinical changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form (fax or online) and document trials of two ophthalmic prostaglandins and two non‑prostaglandin classes or provide justification for intolerance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

(855) 840-1678fax number to submit completed form

5 business daysstandard response time

2prostaglandin alternatives required

2non‑prostaglandin classes required

Coverage Criteria for iDose TR (travoprost implant)

Medical necessity criteria for iDose TR

Covered when ALL of the following are met

1) The patient has a diagnosis for which an intracameral travoprost implant is indicated (e.g., ocular hypertension or open‑angle glaucoma).

2) The requested iDose TR (travoprost implant) will be administered by or under the supervision of an ophthalmologist.

Documented on the form by selecting the applicable checkbox.

3) Documentation of trials of two ophthalmic prostaglandin alternatives (examples include bimatoprost 0.03% or 0.01%, latanoprost 0.005%, travoprost 0.004%, latanoprostene bunod 0.024%, tafluprost 0.0015%, omidenepag 0.002%, others). For each agent include drug name and strength, dates taken, duration, and documented results (inefficacy or intolerable adverse events).

Form requests checkboxes to indicate whether two prostaglandin alternatives were tried and whether they failed or caused adverse events.

Policy Summary

PayerCigna

PolicyiDose TR (travoprost implant) prior authorization / patient information

Policy CodePolicy N/A

Change TypeAdministrative - no material clinical changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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4) Either: (a) The patient tried 2 of the ophthalmic prostaglandin alternatives and they were ineffective; OR (b) The patient tried 2 of the ophthalmic prostaglandin alternatives and experienced adverse events severe enough to warrant discontinuation; OR (c) Other documented clinical rationale.

Represented on the form by selectable options describing outcome of prostaglandin trials.

5) Documentation of trials of two alternatives from different non‑prostaglandin pharmacologic classes (examples: beta‑blockers, alpha‑agonists such as brimonidine, carbonic anhydrase inhibitors, rho kinase inhibitors like netarsudil), including drug name/strength, dates, duration, and outcomes, or documentation of intolerance/adverse events to those alternatives.

Form includes prompts and fields to record these details.

ONE of: 6) Either: (a) The patient tried 2 alternatives from different classes and they were ineffective; OR (b) The patient tried 2 alternatives and experienced adverse events severe enough to warrant discontinuation; OR (c) Other documented clinical rationale.

Represented on the form by selectable options describing outcome of non‑prostaglandin trials.

7) If the request is for retreatment or for concurrent use with Durysta (bimatoprost intracameral implant), the form includes documentation of prior implantation and a clinical rationale for retreatment or concurrent use.

Form asks whether the patient is receiving retreatment and whether Durysta will be used in the same eye(s); if yes, provide rationale.

Place of medication acquisition should be documented on the form. Options include Accredo Specialty Pharmacy (Cigna’s nationally preferred specialty pharmacy), Hospital Outpatient, Retail pharmacy, Home Health / Home Infusion vendor, or Physician's office stock (billing on a medical claim form). The form notes that medication orders can be placed with Accredo via e-prescribe, fax, or verbal channels and provides Accredo contact details.

Requests lacking required clinical documentation—such as detailed trials of specified alternatives (drug name, strength, dates taken, duration, results, and any intolerances or adverse reactions) or an adequate clinical rationale for use—may not meet medical necessity requirements and could render the request not approvable. The form specifically asks providers to document trials of ophthalmic prostaglandins and other classes and to indicate whether alternatives failed due to lack of efficacy or adverse events.

Requested Product and Codes

Requested productmixed

iDose TR 75 mcg implant

Medication requested (implant)

Provider Requirements and Prior Authorization Steps

Prior Authorization

Prior Authorization Required

Prior authorization required — submit a completed request form by fax or online. Attest that all required asterisked patient and prescriber identifiers are completed; incomplete forms may delay processing. Ensure you attest to informed consent and any other submission requirements on the form.

Submit completed form via fax or online per payer instructions
All asterisked (*) patient and prescriber identifiers must be completed
Attest to informed consent and other submission requirements

Step Therapy

Step Therapy / Alternatives

Step therapy: document trials of ophthalmic prostaglandins and at least two alternatives from different pharmacologic classes unless a justification for exception is provided. For each agent tried include drug name, strength, dates taken, duration, and documented results (including intolerances or adverse reactions).

Document trial of 2 ophthalmic prostaglandins (examples: bimatoprost, latanoprost, travoprost, tafluprost, latanoprostene bunod, etc.) — list dates and duration
Document trial of ≥2 alternatives from different classes (e.g., beta-blockers, alpha-agonists like brimonidine, carbonic anhydrase inhibitors, rho kinase inhibitor/netarsudil) — list dates, duration, and outcomes
If exceptions are requested, provide clinical justification for why step therapy was not followed

Documentation Required

Required Form Fields and Clinical Details

Complete all required form fields and clinical details. Include diagnosis, prior therapies tried (with dates, duration, and response), whether therapy was discontinued for adverse events, and whether the medication will be administered by or under supervision of an ophthalmologist. Indicate which eye(s) will be treated and whether this is a re-treatment.

Complete all asterisked patient and prescriber identifiers (physician name, DEA/NPI/TIN, Cigna ID, DOB, etc.)
Provide diagnosis (ICD-10) and medication requested (e.g., iDose TR 75 mcg implant)
Specify administration setting and facility/doctor dispensing information if applicable
Indicate eye(s) to be treated, re-treatment status, and concurrent use of other intracameral implants (e.g., Durysta) with rationale if applicable

Denial Risk

Documentation of Prior Therapies Required

Documentation of prior therapies is required. Failure to document required trials — specifically two ophthalmic prostaglandins and two alternatives from different pharmacologic classes with dates, durations, and outcomes — may result in denial of the request.

Provide drug name, strength, date(s) taken, duration, and documented results for each prior therapy
Indicate if therapies were discontinued due to adverse events or lack of efficacy
Requests lacking adequate documentation of the required trials may be denied

Covered Alternatives and Definitions

Covered alternatives

Topical ophthalmic prostaglandin examplesBimatoprost 0.03% and 0.01% (Lumigan), Latanoprost 0.005% (and latanoprostene bunod 0.024% Vyzulta), Travoprost 0.004%, Xelpros (latanoprost 0.005% emulsion), Tafluprost 0.0015%, Iyuzeh (latanoprost 0.005%), Omlonti (omidenepag isopropyl 0.002%)

Beta‑blockersNon‑prostaglandin topical class option to try and document (e.g., timolol formulations)

Alpha‑agonistBrimonidine listed as an example of a non‑prostaglandin alternative

Carbonic anhydrase inhibitorsTopical carbonic anhydrase inhibitors cited as an alternative class to trial and document

Rho kinase inhibitorNetarsudil listed as an example of a non‑prostaglandin alternative class

Background on iDose TR

iDose TR is a travoprost intracameral implant intended for intraocular delivery of prostaglandin therapy for the treatment of ocular hypertension or open‑angle glaucoma. The prior authorization form requests documentation of prior topical ophthalmic prostaglandin therapies and other ophthalmic agents from different pharmacologic classes, along with clinical details to support the medical necessity of the implant.