CurrentMass General Brigham Health PlanPolicy N/A

iDose TR (travoprost intracameral implant) for open-angle glaucoma/ocular hypertension

Defines prior authorization criteria for coverage of the iDose TR travoprost intracameral implant under the MassHealth medical benefit. Applies to members new to the plan and ongoing use for previously untreated eyes.

Policy Summary

PayerMass General Brigham Health Plan

PolicyiDose TR (travoprost intracameral implant) for open-angle glaucoma/ocular hypertension

Policy CodePolicy N/A

Change TypeNew policy for added drug

Effective DateNov 12, 2024

Next Review DateN/A

Key ActionObtain prior authorization and document qualifying diagnosis, prior Travatan Z trial or reason for implant, and that the treated eye has not previously received iDose TR.

SourceLink

POLICY UPDATE CHANGES

New drug iDose TR (travoprost intracameral implant) was added to criteria and made available through the medical benefit only.

1implant per eye allowed (lifetime)

1 yearmaximum authorization duration per implant

MassHealthplan applicability

Authorization Criteria for iDose TR

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ALL of the following

ANY of the following
- Open-angle glaucoma
- Ocular hypertension
ANY of the following
- Inadequate response or adverse reaction to Travatan Z (travoprost 0.004% ophthalmic solution)
- ANY of the following
  - Limited dexterity
  - Visual impairment
  - Intellectual disability
Affected eye(s) have not previously been treated with iDose TR (travoprost intracameral implant)

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for iDose TR (travoprost intracameral implant) when provided through the medical benefit for MassHealth members. Authorizations for members who are new to the plan but are currently receiving the requested medication may be reviewed on a case-by-case basis (this does not apply when product was obtained as samples or through manufacturer patient assistance).

Applies to iDose TR (medical benefit)
MassHealth members
Case-by-case review for members new to plan currently receiving therapy (excludes samples or manufacturer patient assistance)

Documentation Required

Document diagnosis and prior trial or reason for implant

Prescriber must document a qualifying diagnosis of open-angle glaucoma or ocular hypertension, either an inadequate response or adverse reaction to Travatan Z (travoprost 0.004% ophthalmic solution) or one documented reason making an implantable formulation medically necessary (limited dexterity, visual impairment, or intellectual disability), and that the affected eye(s) have not previously been treated with iDose TR.

Qualifying diagnosis: open-angle glaucoma or ocular hypertension
Inadequate response or adverse reaction to Travatan Z (travoprost 0.004% ophthalmic solution) OR one documented reason for implantable formulation:
- Limited dexterity
- Visual impairment
- Intellectual disability
Treated eye(s) have not previously received iDose TR

Prior Authorization

Recertification documentation for additional eye

For continuation/recertification when treating the other eye, the prescriber must document that the implant is for use in a previously untreated eye.

Clinical and Administrative Context

iDose TR (travoprost intracameral implant) is indicated to reduce intraocular pressure in patients with open-angle glaucoma or ocular hypertension. The plan places iDose TR on the medical benefit, meaning the procedure/implant is administered in a clinical setting rather than through the pharmacy benefit.

This policy establishes prior authorization requirements and eligibility criteria for coverage. Authorization may be granted when the member has a qualifying diagnosis and either an inadequate response or adverse reaction to Travatan Z (travoprost 0.004% ophthalmic solution) or a documented medical necessity for an implantable formulation due to limited dexterity, visual impairment, or intellectual disability. The policy also requires that the affected eye has not previously been treated with iDose TR.

Limitations under this medical benefit policy include approval of up to one iDose TR implant per eye per lifetime and an authorization duration of up to 1 year per approval. Prior authorization is required for MassHealth members, and authorizations for members new to the plan who are currently receiving treatment may be reviewed on a case-by-case basis (excluding samples or manufacturer patient assistance).

Note: Additional agents from this drug class may be available through the pharmacy benefit. See the MassHealth Drug List for coverage and criteria; exceptions and pharmacy-covered agents are handled separately.

Policy Summary

PayerMass General Brigham Health Plan

PolicyiDose TR (travoprost intracameral implant) for open-angle glaucoma/ocular hypertension

Policy CodePolicy N/A

Change TypeNew policy for added drug

Effective DateNov 12, 2024

Next Review DateN/A

Key ActionObtain prior authorization and document qualifying diagnosis, prior Travatan Z trial or reason for implant, and that the treated eye has not previously received iDose TR.

SourceLink

On This Page

OpenPayer

iDose TR (travoprost intracameral implant) for open-angle glaucoma/ocular hypertension

Authorization Criteria for iDose TR

Product References

What Providers Must Do

Clinical and Administrative Context

Defined Terms

Quick Policy Metrics

Policy Changes

iDose TR	travoprost intracameral implant (product name referenced in policy)
Travatan Z	travoprost 0.004% ophthalmic solution (used as prerequisite trial)