CurrentMass General Brigham Health PlanPolicy N/A

Glaucoma topical ocular hypotensive medication step-therapy (prior authorization) coverage criteria

Defines prior authorization and automated step-therapy rules for specified topical glaucoma medications under the pharmacy benefit for Mass General Brigham Health Plan commercial/exchange members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyGlaucoma topical ocular hypotensive medication step-therapy (prior authorization) coverage criteria

Policy CodePolicy N/A

Change TypeCriteria revisednew drug added

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionIf the prescription does not meet initial step therapy requirements at point of sale, submit a prior authorization.

SourceLink

POLICY UPDATE CHANGES

Updated approval criteria to mirror the automated step requirements; effective 02/01/2025.

Added new drug Iyuzeh to criteria as third-line agent.

180look-back window (days)

90new-to-plan window (days)

36 moapproval duration

Commercial/Exchangeplan type

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Tiered step-therapy criteria

Covered when the following tier rules are met:

First-Line Coverage: First-Line agents are covered without prior-authorization.

Second-Line Coverage: Second-line medications will pay if the member has filled a first-line medication or a second-line medication within the past 180 days OR approval can be granted if the member has had an inadequate response or side effect to one first-line medication OR one second-line medication.>=1 prior fill in 180 days or documented inadequate response/side effect

Third-Line Coverage: Third-line medications will pay if the member has filled a second-line medication or a third-line medication within the past 180 days OR approval can be granted if the member has had an inadequate response or side effect to one second-line medication OR one third-line medication.>=1 prior fill in 180 days or documented inadequate response/side effect

Approvals granted for 36 months.

When evaluating a member's prior treatment to determine whether step-therapy requirements are satisfied, products obtained as samples or via manufacturer's patient assistance programs are excluded and should not be counted as prior fills. Documentation of prior therapy must reflect commercially dispensed or otherwise verifiable medication fills; samples and manufacturer-provided assistance products do not qualify for new-to-plan continuity or for meeting prior-fill thresholds.

Covered agents, look-back windows, and coding notes

First-line topical glaucoma agentsmixedCovered

Latanoprost 0.005%

listed as first-line (and referenced for tiering)

Second-line topical glaucoma agentsmixedCovered

Bimatoprost 0.01%	second-line agent
Travoprost 0.004%	second-line agent
Tafluprost 0.0015%	second-line agent

Third-line topical glaucoma agentsmixedCovered

Iyuzeh	latanoprost (listed as third-line agent)
Rhopressa	third-line agent (netarsudil)
Rocklatan	third-line agent (netarsudil/latanoprost)

Prior fill look-back

Prior fill look-back>= fill within past 180 days

Applies toSatisfies step for second- and third-line tiering decisions

UsageMust show a filled first-line (for second-line) or second-line/third-line (for third-line) medication within this window to auto-authorize escalation

New-to-plan continuity window

New-to-plan continuity windowmember new to plan within last 90 days

AllowanceAuthorization may be granted for members new to the plan within 90 days who are currently receiving treatment with a second- or third-line agent

ExclusionsProducts obtained as samples or via manufacturer's patient assistance programs are excluded from consideration

What providers must do at point-of-sale and when to request prior authorization

Denial Risk

POS denial when step not met

If the prescription does not meet the initial step therapy requirements at point-of-sale, the claim will deny with a message that prior authorization (PA) is required. Submit a PA request for members who do not meet the initial step therapy requirements.

Prior Authorization

Prior authorization required when step not met

Prior authorization is required when the member has not met the initial step therapy requirements. First-line agents are covered without PA; second- and third-line approvals require documentation of prior fills or clinical rationale per the step rules below. Submit PA when a claim denies at POS for step therapy.

First-Line: Covered without prior authorization.
Second-Line: Requires a fill of a first- or second-line agent within the past 180 days, or PA documenting inadequate response/side effects to one first- or second-line agent.
Third-Line: Requires a fill of a second- or third-line agent within the past 180 days, or PA documenting inadequate response/side effects to one second- or third-line agent.

Documentation Required

New-to-plan continuity documentation

Members who are new to the plan (within the last 90 days) and are currently receiving treatment with a second- or third-line agent may be eligible for authorization to continue therapy. This exception does not apply when the product was provided as samples or obtained through manufacturer's patient assistance programs. Include documentation confirming prior use and dates of fills when submitting PA for new-to-plan continuity.

Step Therapy

Automated step adjudication and escalation

Step therapy is adjudicated automatically at point-of-sale: first-line agents will pay without prior authorization. If the POS adjudication detects unmet step requirements for a requested second- or third-line agent, the claim will either deny (requiring PA) or escalate to require documentation of prior fills or clinical failure as described above.

Automated adjudication covers first-line agents without PA.
If automated checks find no qualifying prior fill within the required 180-day window, the claim will require PA or documentation of prior failure/side effects.
When escalation to PA is needed, include prior fill history or clinical notes showing inadequate response or intolerance to required prior agents.

Policy background and grouping rationale

This policy groups topical intraocular pressure–lowering agents into tiered categories (first-, second-, and third-line) to enable automated point-of-sale adjudication and to define when prior authorization is required. Escalation between tiers is permitted either by evidence of a qualifying prior fill within the policy look-back window or by documentation of an inadequate response or intolerable side effect. Members who are new to the plan within the last 90 days and who are currently receiving treatment with a second- or third-line agent may be authorized to continue therapy provided the product was not obtained as a sample or through a manufacturer's patient assistance program and appropriate documentation of active treatment and product source is submitted.

Tier definitions

First-Line

First-Line coverageMedications listed on first-line are covered without prior-authorization.

Point-of-sale adjudicationFirst-line agents adjudicate automatically at point of sale without prior authorization.

Role in step therapyServes as the required initial step before second-line escalation unless inadequate response/side effect documented.

Second-Line

Second-Line coverage conditionWill pay if the member has filled a first-line medication or a second-line medication within the past 180 days.

Alternative approval pathApproval can be granted for inadequate response or side effects to one first-line or one second-line medication.

Interaction with POSIf step not met at point of sale, prior authorization required for second-line agents.

Third-Line

Third-Line coverage conditionWill pay if the member has filled a second-line medication or a third-line medication within the past 180 days.

Alternative approval pathApproval can be granted for inadequate response or side effects to one second-line or one third-line medication.

Approval durationApprovals granted for third-line agents are for 36 months when criteria met.