Initial Step-Therapy Requirements — Ophthalmic Steroids
Customize your policy alerts
Sign up for all Mass General Brigham Health Plan policy alerts
Know when Mass General Brigham Health Plan releases new policies or updates existing guidance.
Monitor payer policy activity
Defines pharmacy benefit step-therapy rules for ophthalmic corticosteroid products for Mass General Brigham Health Plan commercial/exchange members; governs point-of-sale adjudication and prior authorization triggers.
Removed loteprednol 0.5% suspension and Lotemax 5% ointment from policy, as agents are moving to nonformulary status.
Moved generic Durezol (difluprednate) to first-line.
Updated prior authorization criteria to include language for members who are new to the plan requiring documentation of current treatment if coverage effective date is ≤ 90 days.
Step-Therapy Coverage Criteria
Ophthalmic steroid step-therapy criteria
Covered when ALL of the following structured step-therapy conditions are met:
ALL of the following
- First-line coverage: Medications listed as first-line are covered without prior authorization (see policy first-line list).
- Second-line automatic coverage conditions: Second-line medications will pay if the member has filled at least two different first-line medications or has filled a second-line medication within the past 180 days.
Look-back period = 180 days
- New-to-plan documentation exception: If member is new to the plan (coverage effective date ≤ 90 days), submit medical records documenting current treatment with the requested drug. Documentation must exclude samples and manufacturer patient assistance program supplies.
- Authorization alternative for inadequate response/intolerance/contraindication: Authorization may be granted when member has had an inadequate response, intolerance, or contraindication to at least two first-line ophthalmic corticosteroids or to one second-line ophthalmic corticosteroid.
- Operational note: Prescriptions that meet the initial step-therapy requirements will adjudicate automatically at point-of-sale; those that do not will deny at point-of-sale with a message indicating prior authorization is required.
Agents and Coding Rules
| difluprednate ophthalmic emulsion | difluprednate ophthalmic emulsion |
| dexamethasone ophthalmic | dexamethasone ophthalmic |
| fluorometholone ophthalmic | fluorometholone ophthalmic |
| prednisolone ophthalmic | prednisolone ophthalmic |
| Lotemax SM 0.38% ophthalmic gel | Lotemax SM 0.38% ophthalmic gel |
| loteprednol 0.5% ophthalmic gel | loteprednol 0.5% ophthalmic gel |
| FIRST-LINE, 1 | FIRST-LINE, 1 = SECOND-LINE (policy notation) |
Point-of-Sale and Authorization Actions
Point-of-sale adjudication — submit PA when claim denies
Prescriptions that meet the initial step-therapy requirements will adjudicate automatically at point of sale; prescriptions that do not meet the initial step-therapy requirements will deny at point of sale with a message that prior authorization (PA) is required. Submit a PA request at the point of sale for any member who does not meet the initial step-therapy requirements.
- Check member history against the step-therapy criteria prior to dispensing.
- If the claim denies with a PA-required message, initiate and submit the PA request promptly to avoid care delays.
Authorization criteria and documentation for new members
Authorization may be granted when the member has had an inadequate response, intolerance, or contraindication to at least two first-line ophthalmic corticosteroids or to one second-line ophthalmic corticosteroid. For members new to the plan (coverage effective date ≤ 90 days), submit medical records documenting current treatment with the requested drug (excluding samples or manufacturer patient assistance programs).
- Include documentation showing trials and outcomes for at least two first-line agents or documentation of a second-line trial as applicable.
- For new-to-plan members, provide medical records demonstrating ongoing treatment with the requested product (do not submit documentation of samples or manufacturer patient assistance program supplies).
Definitions and Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.