Initial Step-Therapy Requirements — Glaucoma Agents
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Defines initial step-therapy sequencing, prior-authorization triggers, and coverage rules for specified glaucoma drugs under the pharmacy benefit for Mass General Brigham Health Plan commercial/exchange members.
No material clinical or coverage changes in this revision.
Glaucoma Step-Therapy Coverage Criteria
Glaucoma step-therapy coverage criteria
Coverage and step criteria for glaucoma agents
Step tiers
- First-Line: Medications designated as First-Line are covered without prior authorization.
- Second-Line medications will be covered if the member has a fill for a First-Line or a Second-Line medication within the prior 180 days.
- Third-Line medications will be covered if the member has a fill for a Second-Line or a Third-Line medication within the prior 180 days.
Initial Step Placements
Initial step placements
Specified initial step-therapy placements for listed glaucoma agents.
Continuation / Transition
Continuation/Transition
Continuation or transition for members new to plan
Provider Actions and Prior Authorization
Prior authorization required when step criteria not met
Prescriptions that meet the initial step therapy requirements will adjudicate automatically at the point of sale; prescriptions that do not meet the initial step therapy requirements will deny with a message indicating prior authorization (PA) is required. Submit a PA request for members who do not meet the initial step therapy requirements at the point of sale.
- Point-of-sale adjudication for prescriptions that meet initial step criteria.
- Point-of-sale denial with instruction that PA is required when criteria are not met; provider must submit PA request.
Provide medical records for new-to-plan members
For members new to the plan (coverage effective ≤ 90 days), submit medical records documenting that the member is currently receiving the requested drug (exclude samples or manufacturer patient assistance). Documentation is also required to support PA when step criteria are not met.
- New-to-plan window: coverage effective date ≤ 90 days triggers documentation requirement.
- Documentation must show current receipt of the requested drug and excludes samples or manufacturer assistance programs.
- When step criteria are not met, PA requests should include clinical records documenting inadequate response or side effects to required prior-line medication as applicable.
Coding and Lookback
| No codes listed |
Step Therapy Tier Definitions
Operational Step-Therapy Rules
| Requirement | Details |
|---|---|
| {"text":"Prior-fill requirement","status":""},{"text":"Member must have filled the required prior-tier medication within the prior 180 days to meet step-therapy for a later-line agent.","status":""} | |
| {"text":"Clinical failure / intolerance documentation","status":""},{"text":"If prior fills are not available, prior authorization (PA) may be approved with documentation that the member had an inadequate response or experienced side effects to one agent of the required prior tier.","status":""} | |
| {"text":"New-to-plan members","status":""},{"text":"For members new to the plan (coverage effective ≤ 90 days), submit medical records documenting current treatment with the requested product to support continuation or PA consideration.","status":""} | |
| {"text":"Adjudication and PA action","status":""},{"text":"Prescriptions that meet the initial step therapy requirements will adjudicate automatically at point of sale; prescriptions that do not meet requirements will deny with a message indicating prior authorization is required.","status":""} |
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