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    v1.0.30
    OpenPayerPolicy UpdatesOphthalmology/OptometryMass General Brigham iDose TR Prior Auth | OpenPay…
    Ask Trek AI about this page
    ModifiedMass General Brigham Health PlanPolicy N/A

    Glaucoma Agents iDose TR (travoprost intracameral implant)

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    This policy governs MassHealth prior authorization and continuation or recertification of iDose TR (travoprost intracameral implant) through the medical benefit. It applies to members receiving treatment for open-angle glaucoma or ocular hypertension and specifies clinical, documentation, safety, and timing requirements.

    Policy Summary
    PayerMass General Brigham Health Plan
    PolicyGlaucoma Agents iDose TR (travoprost intracameral implant)
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateJan 4, 202757d
    Last ReviewNov 4, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization through the medical benefit for initial treatment or recertification, with all required clinical and endothelial-cell documentation.
    SourceLink
    POLICY UPDATE CHANGES

    The criteria were updated to address re-administration of iDose TR after updated product labeling allowed repeat implantation.

    The policy references were updated during the November 2026 review.

    3 monthsInitial approval and reauthorization duration
    >365 daysMinimum interval since prior iDose TR implantation for recertification
    3Topical product classes/products requiring inadequate response or adverse reaction under one initial-authorization pathway
    <10%Maximum central corneal endothelial cell loss from pre-administration baseline for continuation
    ≥3 yearsImplant duration after which loss of effectiveness can support another iDose TR

    Coverage Criteria

    New-to-plan current therapy

    For members new to the plan, submit documentation of current treatment.

    New-to-plan continuation documentation: The member's coverage effective date is less than or equal to 90 days, and medical records document that the member is currently receiving treatment with the requested drug.Coverage effective date ≤90 days

    Treatment obtained as samples or through a manufacturer's patient assistance program is excluded from this documentation pathway.

    Initial authorization

    Authorization may be granted when all of the following criteria are met.

    • Covered diagnosis

      • Open-angle glaucoma: Diagnosis of open-angle glaucoma.
      • Ocular hypertension: Diagnosis of ocular hypertension.
    • Dosing and treated eye documentation: Appropriate dosing is documented, including the specific eye(s) to be treated.
    • Age: The member is at least 18 years of age.≥18 years
    • Prescriber specialty: The prescriber is an ophthalmologist.

    • Prior treatment failure or implant medical necessity

      • Inadequate response or adverse reaction: The member has an inadequate response or adverse reaction to combination treatment with THREE of the following topical products: carbonic anhydrase inhibitor, ophthalmic alpha-2 adrenergic agonist, ophthalmic beta-blocker, parasympathomimetic, prostaglandin analog, or Rhopressa (netarsudil).Three topical products

        Examples in the policy include dorzolamide, brimonidine, and pilocarpine.

      • Medical necessity for implantable formulation

        • Limited dexterity.
        • Visual impairment.
        • Intellectual disability.
    • Durysta alternative rationale: Clinical rationale is provided for use of the requested agent instead of Durysta.
    • Baseline endothelial cell density: Baseline central corneal endothelial cell density is provided and is above the minimum density threshold based on the phakic or pseudophakic eye(s).Above applicable minimum threshold

    Continuation therapy and recertification

    Recertification can be issued for another iDose TR when all of the following are documented.

    • Dosing and treated eye documentation: Appropriate dosing is documented, including the specific eye(s) to be treated.
    • Time since prior implantation: The previous iDose TR was implanted in the target eye(s) more than 365 days ago.>365 days

    • Continued need or loss of effectiveness

      • Implant supplementation or implant medical necessity

        • Current implant under 3 years: The current implant is less than 3 years old and clinical rationale explains why the iDose TR cannot be supplemented by a topical product.<3 years

        • Medical necessity for implantable formulation

          • Limited dexterity.
          • Visual impairment.
          • Intellectual disability.
      • Implant no longer effective: The iDose TR has been implanted for at least 3 years and is no longer effective.≥3 years
    • Baseline endothelial density and cell loss: Both baseline central corneal endothelial cell density based on the phakic or pseudophakic eye(s) and central corneal endothelial cell loss of less than 10% from the pre-administration baseline are documented.Cell loss <10%
    • Current endothelial cell density: The member's current endothelial cell density is above the minimum recommended threshold based on the phakic or pseudophakic eye(s).Above applicable minimum recommended threshold
    • Device history: There is no history of prior iDose TR device dislocation.No prior dislocation

    For members whose coverage effective date is 90 days or less before submission, treatment records must document that the member is currently receiving the requested drug. Treatment obtained as samples or through a manufacturer’s patient assistance program does not satisfy this new-to-plan documentation pathway.

    A history of prior iDose TR device dislocation is not compatible with recertification for another iDose TR and must be absent for continuation authorization.

    Clinical Thresholds and Treatment Parameters

    Baseline central corneal endothelial cell density
    Baseline measurementCentral corneal endothelial cell density value must be provided.
    Phakic eyeBaseline density must be above the minimum density threshold applicable to the phakic eye.
    Pseudophakic eyeBaseline density must be above the minimum density threshold applicable to the pseudophakic eye.
    Interval since previous iDose TR implantation
    Required intervalThe previous iDose TR must have been implanted in the target eye(s) more than 365 days ago.
    Not sufficientAn implant placed 365 days ago or less does not meet the recertification timing requirement.
    ApplicationThe interval applies to recertification for another iDose TR.
    Central corneal endothelial cell loss
    Maximum permitted lossCentral corneal endothelial cell loss must be less than 10% from the pre-administration baseline.
    Measurement basisCell loss is measured from the pre-administration baseline.
    Recertification requirementThe cell-loss requirement applies to recertification for another iDose TR.
    Current central corneal endothelial cell density
    Current measurementCurrent endothelial cell density must be documented.
    Phakic eyeCurrent density must be above the minimum recommended threshold applicable to the phakic eye.
    Pseudophakic eyeCurrent density must be above the minimum recommended threshold applicable to the pseudophakic eye.
    Current implant duration
    Implant duration under 3 yearsThe current implant is less than 3 years old and clinical rationale must explain why iDose TR cannot be supplemented by a topical product.
    Implant duration 3 years or longeriDose TR has been implanted for at least 3 years and is no longer effective.
    Alternative implant rationaleMedical necessity for an implantable formulation may be based on limited dexterity, visual impairment, or intellectual disability.
    Required prior topical treatment
    Required treatment historyThe member must have an inadequate response or adverse reaction to combination treatment with three listed topical products.
    Carbonic anhydrase inhibitorOne listed topical option; example: dorzolamide.
    Ophthalmic alpha-2 adrenergic agonistOne listed topical option; example: brimonidine.
    Ophthalmic beta-blockerOne listed topical option.
    ParasympathomimeticOne listed topical option; example: pilocarpine.
    Prostaglandin analogOne listed topical option.
    RhopressaOne listed topical option: Rhopressa (netarsudil).

    Authorization and Documentation Requirements

    Prior Authorization

    Initial Prior Authorization Required

    Prior authorization is required for iDose TR under the MassHealth Uniform Preferred Products List (UPPL) medical benefit. Initial authorization is subject to the clinical and documentation requirements below.

    • Coverage is under the medical benefit; pharmacy benefit requirements do not apply.
    • The requested product is travoprost intracameral implant (iDose TR).
    Prior Authorization

    Continuation Prior Authorization

    For continuation of therapy, the prescriber must obtain recertification before another iDose TR implant is authorized and submit documentation demonstrating that all continuation requirements remain satisfied.

    • The prior iDose TR must have been implanted in the target eye(s) more than 365 days ago.
    • Submit current clinical, endothelial-cell, dosing, and safety documentation with the recertification request.
    Step Therapy

    Failure or Intolerance of Three Topical Options

    The member must have an inadequate response or adverse reaction to a combination of three eligible topical products, unless medical necessity for an implantable formulation is documented.

    • Eligible topical categories include a carbonic anhydrase inhibitor, ophthalmic alpha-2 adrenergic agonist, ophthalmic beta-blocker, parasympathomimetic, prostaglandin analog, or Rhopressa (netarsudil).
    • Alternatively, document medical necessity for an implantable formulation because of limited dexterity, visual impairment, or intellectual disability.
    Documentation Required

    New-to-Plan Current Treatment Records

    If the member's coverage effective date is 90 days or less before submission, provide medical records documenting that the member is currently receiving the requested drug.

    • Do not use samples or manufacturer patient assistance program supply as evidence of current treatment.
    Documentation Required

    Initial Authorization Clinical Documentation

    Initial requests must include clinical documentation supporting the diagnosis and planned treatment, including the specific eye(s) to be treated and the requested dosing.

    • Document open-angle glaucoma or ocular hypertension.
    • Member must be 18 years of age or older.
    • Prescriber must be an ophthalmologist.
    • Document the qualifying topical treatment history or medical necessity for an implantable formulation.
    • Provide clinical rationale for using iDose TR instead of Durysta.
    Documentation Required

    Baseline Endothelial Cell Documentation

    Provide the baseline central corneal endothelial cell density for each applicable target eye and demonstrate that the value exceeds the minimum recommended threshold for the eye's phakic or pseudophakic status.

    • Document whether each target eye is phakic or pseudophakic.
    • Include the baseline endothelial cell density value and the applicable minimum threshold.
    Documentation Required

    Continuation and Recertification Documentation

    Continuation requests must document appropriate dosing and the specific eye(s) to be treated, the prior iDose TR implantation date, and the clinical rationale supporting another implant.

    • The prior implant must have been placed in the target eye(s) more than 365 days earlier.
    • If the current implant is less than 3 years old, explain why it cannot be supplemented by a topical product, or document limited dexterity, visual impairment, or intellectual disability.
    • If iDose TR has been implanted for 3 years or more, document that it is no longer effective.
    • Document baseline endothelial cell density by phakic or pseudophakic eye status, endothelial cell loss of less than 10% from pre-administration baseline, and a current density above the applicable minimum threshold.
    • Confirm no history of prior iDose TR device dislocation.
    Denial Risk

    Initial Authorization Criteria Not Met

    Initial authorization is not clinically eligible when the request does not satisfy the required diagnosis, age, prescriber, dosing, treatment-history, or clinical-rationale criteria.

    • Deny when the diagnosis is not open-angle glaucoma or ocular hypertension.
    • Deny when the member is younger than 18 or the prescriber is not an ophthalmologist.
    • Deny when appropriate dosing or the target eye(s) are not documented.
    • Deny when neither inadequate response/adverse reaction to three eligible topical products nor qualifying medical necessity for an implantable formulation is documented.
    • Deny when clinical rationale for iDose TR instead of Durysta is not provided.
    Denial Risk

    Continuation Safety or Timing Criteria Not Met

    Continuation authorization should not be issued when timing, endothelial-cell, effectiveness, safety, or documentation requirements are not met.

    • Deny when the prior iDose TR was implanted in the target eye(s) 365 days ago or less.
    • Deny when required baseline or current endothelial cell density documentation is missing, below the applicable minimum threshold, or when endothelial cell loss is 10% or more from pre-administration baseline.
    • Deny when the required continuation rationale is absent, including why a topical product cannot supplement an implant that is less than 3 years old or evidence that an implant in place for 3 years or more is no longer effective.
    • Deny when there is a history of prior iDose TR device dislocation.
    • Deny when appropriate dosing or the target eye(s) are not documented.
    Denial Risk

    New-to-Plan Treatment History Not Documented

    For new-to-plan members, failure to document current treatment with the requested drug creates a documentation gap and may result in denial or a request for additional records.

    • Apply when the coverage effective date is 90 days or less before submission.
    • Records must show current treatment with iDose TR.
    • Treatment obtained solely through samples or a manufacturer's patient assistance program does not satisfy this requirement.

    Policy and Treatment Background

    iDose TR is a travoprost intracameral implant used to reduce elevated intraocular pressure. The policy identifies open-angle glaucoma and ocular hypertension as covered indications, subject to the applicable authorization and safety requirements.

    Definitions

    OAG
    AbbreviationOAG.
    TermOpen-angle glaucoma.
    Policy indicationOpen-angle glaucoma is identified as an indication for iDose TR.
    OHT
    AbbreviationOHT.
    TermOcular hypertension.
    Policy indicationOcular hypertension is identified as an indication for iDose TR.
    iDose TR
    Product nameiDose TR.
    Active treatment and formulationTravoprost intracameral implant.
    PurposeUsed to reduce elevated intraocular pressure.
    Phakic or pseudophakic eye
    Phakic eyeA treated eye classified as phakic for applying the endothelial cell density threshold.
    Pseudophakic eyeA treated eye classified as pseudophakic for applying the endothelial cell density threshold.
    Threshold applicationBaseline and current central corneal endothelial cell density thresholds are based on whether the treated eye is phakic or pseudophakic.
    Policy Summary
    PayerMass General Brigham Health Plan
    PolicyGlaucoma Agents iDose TR (travoprost intracameral implant)
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateJan 4, 202757d
    Last ReviewNov 4, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization through the medical benefit for initial treatment or recertification, with all required clinical and endothelial-cell documentation.
    SourceLink
    On This Page
    Coverage CriteriaClinical Thresholds and Treatment ParametersAuthorization and Documentation RequirementsPolicy and Treatment BackgroundDefinitions

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