CurrentMass General Brigham Health PlanPolicy N/A

Ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) — Pharmacy Coverage Criteria

Defines prior authorization, step therapy, and quantity limits for ophthalmic NSAID products under the pharmacy benefit for Mass General Brigham Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyOphthalmic NSAIDs — Pharmacy Coverage Criteria

Policy CodePolicy N/A

Change TypeFormulary/operational

Effective DateMar 1, 2024

Next Review DateN/A

Key ActionSubmit a prior authorization request for members who do not meet initial step-therapy requirements (or document two different first-line failures for PA approval).

SourceLink

POLICY UPDATE CHANGES

Bromfenac (generic for Prolensa) was released and replaced Prolensa as a second-line agent; brand Prolensa moved to non-formulary effective 3/1/2024.

12 moApproval duration

180 daysLook-back period

2First-line trials required

DefinedQuantity limits

Coverage and Clinical Criteria

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Second-Line Coverage Criteria

Covered when ONE of the following is met:

Two first-line fills within look-back: Member has filled at least two different first-line medications within the past 180 days2 different first-line fills within 180 days

Per step therapy rules

Recent second-line fill: Member has filled a second-line medication within the past 180 days1 second-line fill within 180 days

Alternative pathway to automatic payment

PA Approval Conditions

Approval of a second-line medication via PA requires ALL of the following:

PA approval requirements: Documented inadequate response or side effect to at least two different first-line topical corticosteroidstwo different first-line corticosteroids tried

Provider must document inadequate response or intolerable side effects to each agent

The formulary placement for bromfenac-containing products has been updated effective 3/1/2024: the brand product Prolensa (bromfenac) has been moved to non-formulary (NF). The generic bromfenac is designated as the listed second-line agent. Retain awareness that quantity limits remain defined for bromfenac products (see Quantity Limits).

Prescriber and Pharmacy Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required when a prescription does not meet the plan's initial step-therapy requirements at the point of sale. Submit a PA request for members who fail step therapy. Approval requires documentation that step-therapy criteria are met or that exceptions apply.

Submit PA via the usual payer portal or fax with clinical justification.
Include documentation of prior medication trials, dates, and reason for failure (lack of efficacy or adverse effects).

Step Therapy

Initial Step-Therapy Requirements

First-line topical agents listed by the plan are covered without prior authorization and will adjudicate at the point of sale if step therapy is met.

First-line agents: topical corticosteroids (as defined by the plan formulary).
Second-line agents require prior trials as described below.

Documentation Required

Submit Prior Authorization When Step Therapy Not Met

For members who do not meet step therapy at point of sale, submit a prior authorization request. The PA should document prior medication history and the clinical rationale for starting a second-line agent.

If prescription denies at POS with a message that PA is required, follow PA submission instructions.
Attach pharmacy fill history showing trials of first-line agents when available.

Denial Risk

Step Therapy Denial Risk at Point of Sale

Prescriptions that do not meet the initial step-therapy requirements will deny at the point of sale. A PA must be submitted to obtain coverage for second-line medications; approval is contingent on meeting the documented criteria (two different first-line topical corticosteroid failures or a recent second-line fill within look-back).

Denial at POS will instruct provider to request prior authorization.
Look-back period for a qualifying second-line fill: 180 days.
Qualifying prior trials: at least two different first-line topical corticosteroids with documented inadequate response or adverse effects.

First-Line Therapy — No Prior Authorization

First-Line Coverage

First-line agents covered without prior authorization

First-line listing: Medications listed as first-line are covered without prior authorizationN/A

Refer to the policy first-line list (e.g., diclofenac 0.1% Voltaren; flurbiprofen 0.03% Ocufen; ketorolac formulations)

Requirement	Look-back period	To avoid prior authorization
Try two different first-line agents (or have a second-line fill)	180 days	Member has filled at least two different first-line medications OR has filled a second-line medication within the past 180 days

Drug-Specific Dispensing Limits

inv-13: diclofenac 0.1% (Voltaren) — quantity limit details (5 mL)

Medicationdiclofenac 0.1% (Voltaren)

Quantity limit5 mL per course

Approval durationUp to 12 months within the quantity limit

inv-14: flurbiprofen 0.03% (Ocufen) — quantity limit details (5 mL)

Medicationflurbiprofen 0.03% (Ocufen)

Quantity limit5 mL per course

Approval durationUp to 12 months within the quantity limit

inv-15: ketorolac 0.5% (Acular) — quantity limit details (10 mL per 25 days)

Medicationketorolac 0.5% (Acular)

Quantity limit10 mL per 25 days (5 mL = 10 mL per 25 days as listed)

Approval durationUp to 12 months within the quantity limit

inv-16: bromfenac 0.09% (compare to Xibrom) — quantity limit details (5 mL)

Medicationbromfenac 0.09% (compare to Xibrom)

Quantity limit5 mL per course

NoteBromfenac is listed as a second-line agent (compare to Xibrom)

inv-17: Acuvail (ketorolac) 0.45% — quantity limit details (60 single-use vials / 2 boxes)

MedicationAcuvail (ketorolac) 0.45%

Quantity limit60 single-use vials (2 boxes)

Approval durationUp to 12 months within the quantity limit

inv-18: Ilevro (nepafenac) 0.3% — quantity limit details (1.7 mL per 5 mL unit)

MedicationIlevro (nepafenac) 0.3%

Quantity limit1.7 mL per 5 mL unit

Approval durationUp to 12 months within the quantity limit

inv-19: Nevanac (nepafenac) 0.1% — quantity limit details (3 mL per 5 mL unit)

MedicationNevanac (nepafenac) 0.1%

Quantity limit3 mL per 5 mL unit

Approval durationUp to 12 months within the quantity limit

inv-20: Prolensa (bromfenac) 0.07% — quantity limit details (3.2 mL per 5 mL unit)

MedicationProlensa (bromfenac) 0.07%

Quantity limit3.2 mL per 5 mL unit

Formulary statusBrand Prolensa moved to non-formulary; bromfenac generic listed as second-line

Key Terms and Classifications

inv-09: first-line — Definition / list of first-line medications

DefinitionFirst-line medications are topical ophthalmic NSAIDs listed as covered without prior authorization

Included agentsdiclofenac 0.1% (Voltaren); flurbiprofen 0.03% (Ocufen); ketorolac 0.4% (Acular LS); ketorolac 0.5% (Acular)

Coverage noteFirst-line agents adjudicate automatically at point of sale when step-therapy requirements are met

inv-10: second-line — Definition / second-line medications (require trial/failure of first-line or PA criteria)

DefinitionSecond-line medications require trial/failure of first-line agents or prior authorization when step therapy unmet

Included agentsbromfenac (compare to Xibrom) 0.09%; Acuvail (ketorolac) 0.45%; Ilevro (nepafenac) 0.3%; Nevanac (nepafenac) 0.1%; bromfenac (Prolensa) 0.07%

PA requirementApproval via prior authorization requires documented inadequate response or side effects to at least two different first-line topical corticosteroids

Clinical Background

Topical ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) are indicated for management of postoperative ocular inflammation and ocular pain. This policy governs coverage for ophthalmic NSAIDs under the pharmacy benefit, distinguishing first-line agents (covered without prior authorization) from second-line agents (which require either meeting step-therapy fill history or prior authorization). Quantity limits and an approval duration of 12 months apply to covered approvals; specific product volume limits are listed in the Quantity Limits section.

Policy Summary

PayerMass General Brigham Health Plan

PolicyOphthalmic NSAIDs — Pharmacy Coverage Criteria

Policy CodePolicy N/A

Change TypeFormulary/operational

Effective DateMar 1, 2024

Next Review DateN/A

Key ActionSubmit a prior authorization request for members who do not meet initial step-therapy requirements (or document two different first-line failures for PA approval).

SourceLink

On This Page

OpenPayer

Ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) — Pharmacy Coverage Criteria

Coverage and Clinical Criteria

Prescriber and Pharmacy Actions

First-Line Therapy — No Prior Authorization

Step Therapy Requirements

Drug-Specific Dispensing Limits

Key Terms and Classifications

Clinical Background

Policy Changes and Effective Dates