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    v1.0.28
    OpenPayerPolicy UpdatesOphthalmology/OptometryCommunity-Care Durysta Coverage & Prior Auth | Ope…
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    CurrentCommunity-CarePolicy N/A

    Durysta (bimatoprost intracameral implant) — Coverage Criteria

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    Medical benefit medication utilization policy governing coverage and authorization criteria for Durysta (bimatoprost intracameral implant) for treating elevated intraocular pressure in adults; applies to providers and members under the payer's jurisdiction.

    Policy Summary
    PayerCommunity-Care
    PolicyDurysta (bimatoprost intracameral implant) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Last ReviewSep 1, 2024
    Next Review DateSep 1, 2024
    Key ActionObtain prior authorization demonstrating all coverage criteria are met before approval (use HCPCS J7351 for billing).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1 implant/eye/lifetimequantity limit
    2 implants/lifetimemaximum implants
    ≥18 yrsmin age

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1 year
    auth period

    Coverage Criteria for Durysta (bimatoprost intracameral implant)

    Initial Approval — Covered when ALL of the following are met

    Covered when ALL of the following are met

    Initial Approval Criteria: 1) Diagnosis of open-angle glaucoma OR ocular hypertension; 2) Prescribed by, or in consultation with, an ophthalmologist; 3) Patient aged >= 18 years; 4) Trial of all of the following were ineffective, contraindicated, or not tolerated: (a) two different ophthalmic prostaglandin analogs AND (b) a third ophthalmic agent with a different mechanism of action (e.g., beta-blockers, alpha-adrenergic agonists, parasympathomimetic agents, rho-kinase inhibitors, or carbonic anhydrase inhibitors); 5) The affected eye has not received prior treatment with bimatoprost intracameral implant (Durysta).

    All listed conditions required for initial approval.

    Prior treatment with a bimatoprost intracameral implant (Durysta) in the affected eye excludes initial approval for that eye. Documented evidence that the eye has previously received Durysta will result in denial of initial coverage for that eye.

    Applicable Codes and Implant Potency

    Applicable HCPCS CodesHCPCSCovered
    J7351Injection, bimatoprost, intracameral implant, 1 microgram
    Implant potency
    Implant potency1 implant = 10 mcg (billing unit defined as 1 microgram per J7351)
    Billing unit mappingHCPCS J7351 describes the service as 'Injection, bimatoprost, intracameral implant, 1 microgram'
    Units per implantPolicy defines 1 implant = 1 unit for authorization/quantity limits

    Prior Authorization, Step Therapy, and Documentation Requirements

    Prior Authorization

    Prior authorization required; bill with J7351

    Prior authorization is required and approval will only be granted when all coverage criteria are met. Bill the implant using HCPCS code J7351 (Injection, bimatoprost, intracameral implant, 1 microgram).

    • Prior authorization required before approval
    • Use HCPCS code J7351 for billing (injection, bimatoprost, intracameral implant, 1 microgram)
    Step Therapy

    Step therapy: document trials of required topical agents

    Document prior trials demonstrating that two different topical ophthalmic prostaglandin analogs were ineffective, contraindicated, or not tolerated, plus a trial of a third ophthalmic agent with a different mechanism of action (for example beta-blocker, alpha-adrenergic agonist, parasympathomimetic, rho-kinase inhibitor, or carbonic anhydrase inhibitor).

    • Two different ophthalmic prostaglandin analogs

    Background

    Durysta is an intracameral bimatoprost implant intended to reduce intraocular pressure in patients with open-angle glaucoma or ocular hypertension. Coverage under this policy requires meeting the stated clinical criteria, including specialist involvement, appropriate prior topical therapy attempts, and that the treated eye has not previously received the implant.

    Definitions

    Elevated intraocular pressure
    Clinical contextPatients with elevated intraocular pressure defined as a diagnosis of open‑angle glaucoma OR ocular hypertension for whom intraocular pressure reduction is indicated
    Age requirementPatient must be aged ≥ 18 years
    Specialist involvementPrescribed by, or in consultation with, an ophthalmologist
    Prior implant exclusionThe affected eye must not have received prior treatment with bimatoprost intracameral implant (Durysta)
    Durysta (bimatoprost intracameral implant)
    Product descriptionDurysta is an intracameral bimatoprost implant providing 10 mcg per implant and intended to reduce intraocular pressure
    Policy Summary
    PayerCommunity-Care
    PolicyDurysta (bimatoprost intracameral implant) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Last ReviewSep 1, 2024
    Next Review DateSep 1, 2024
    Key ActionObtain prior authorization demonstrating all coverage criteria are met before approval (use HCPCS J7351 for billing).
    SourceLink
    On This Page
    Coverage Criteria for Durysta (bimatoprost intracameral implant)Applicable Codes and Implant PotencyPrior Authorization, Step Therapy, and Documentation RequirementsBackgroundDefinitions
  1. One additional ophthalmic agent with a different mechanism (examples listed in policy)
    2. Documentation Required

    Required clinical documentation to support authorization

    Include clinical documentation showing the diagnosis (open-angle glaucoma or ocular hypertension), patient is aged ≥18 years, that the prescriber is an ophthalmologist or consulted one, evidence of the required prior medication trials (or reasons they were ineffective/contraindicated/not tolerated), and that the affected eye has not previously received Durysta.

    • Diagnosis: open-angle glaucoma OR ocular hypertension
    • Patient age ≥ 18 years
    • Prescriber is an ophthalmologist or documentation of ophthalmology consultation
    • Documentation of prior trials (two prostaglandin analogs and a third agent) or rationale if not attempted
    • Confirmation the affected eye has not previously received bimatoprost intracameral implant (Durysta)
    Denial Risk

    Denial risk if coverage criteria are not met

    Requests that do not meet all listed clinical criteria — including lack of required diagnosis, age <18, absence of documented prior medication trials, prior Durysta in the affected eye, or lack of ophthalmologist involvement — may be denied.

    • No documented diagnosis of open-angle glaucoma or ocular hypertension
    • Patient under 18 years of age
    • Missing documentation of required prior trials of two prostaglandin analogs and a third different-mechanism agent
    • Affected eye has prior treatment with bimatoprost intracameral implant
    • Prescriber not an ophthalmologist and no documented consultation
    HCPCS codeJ7351 — Injection, bimatoprost, intracameral implant, 1 microgram
    Billing noteBilling uses J7351 with 1 microgram units; 1 implant equals 10 microgram (10 units) for billing calculations
    Quantity limit contextPolicy authorizes up to 1 implant/eye/lifetime (2 implants/patient lifetime)