CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Durysta (bimatoprost) (Implant)

This policy governs prior authorization, medical necessity, and coverage limits for the Durysta intracameral bimatoprost implant for members of Neighborhood Health Plan of Rhode Island across Medicaid, Commercial, and Medicare-Medicaid Plan populations.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDurysta (bimatoprost) (Implant)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization documenting age, diagnosis, prior intolerance or insufficient response to at least two prostaglandin analogs plus one other IOP-lowering class, and intended eye before approving a one-time Durysta implant per eye.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

one-timeimplant administrations per eye

10 mcgimplant dose

>=18minimum age

J7351billing code

requiredstep therapy

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Coverage Criteria

Initial Therapy

Covered when ALL of the following are met:

Age: Member is 18 years of age or older>=18 years

Diagnosis of open angle glaucoma or ocular hypertension

Prescriber: Durysta has been prescribed by or in consultation with an ophthalmologist

Prior therapy: Intolerance or insufficient response to at least two ophthalmic prostaglandin analogs (e.g., latanoprost, travoprost, tafluprost, bimatoprost) AND at least one other IOP‑reducing ophthalmic product from a different medication class (e.g., beta‑blockers, alpha‑agonists, carbonic anhydrase inhibitors). Combination therapy should be used if warranted.

Contraindications absent: No active or suspected ocular or periocular infection; no diagnosis of corneal endothelial cell dystrophy (e.g., Fuchs' dystrophy); no history of corneal transplantation or endothelial cell transplant; intact (not absent or ruptured) posterior lens capsule; no hypersensitivity to bimatoprost or any component of Durysta

No prior Durysta in same eye: The affected eye has not received prior treatment with Durysta (bimatoprost)

No concurrent iDose TR: Member will not concurrently use Durysta (bimatoprost intracameral implant) with iDose TR (travoprost intracameral implant)

Durysta is approved as a single intracameral administration containing 10 mcg of bimatoprost per eye. Use of Durysta at any dose other than the FDA‑approved 10 mcg intracameral single administration is not covered. The policy specifies a maximum billable amount of 10 units (1 unit = 1 mcg) per eye per lifetime and does not provide coverage for dosing beyond this limit.

Therapies used at a dose or for a condition other than those recognized as medically accepted indications are considered investigational and are not covered. Investigational use is defined by reliance on standard reference compendia or peer‑reviewed literature to establish accepted indications; if such sources do not support the dose or condition, coverage will be denied.

Coding and Billing

Applicable HCPCS/CPT CodesHCPCSCovered

J7351

Injection, bimatoprost, intracameral implant, 1 microgram

Coding threshold

Maximum billable units per eye10 units per eye per lifetime (1 unit = 1 mcg)

Unit definition1 billable unit = 1 microgram of bimatoprost

Lifetime limitCoverage limited to a maximum of 10 units billed for each eye over the member's lifetime

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Lifetime Limit

Durysta (bimatoprost intracameral implant) requires prior authorization and will be reviewed prospectively. Coverage is limited to one implant per eye per lifetime; renewal is not allowed.

Prior authorization required for medical benefit coverage
Coverage limited to one implant per eye per lifetime (not renewable)

Documentation Required

Required Documentation for Prior Authorization

Prior authorization requests must include documentation supporting patient eligibility and medical necessity. Missing or incomplete documentation may delay or result in denial of the request.

Document age (must be ≥ 18 years)
Document diagnosis of open-angle glaucoma or ocular hypertension

Definitions

Durysta (bimatoprost) implant

Product descriptionDurysta is a biodegradable ophthalmic drug delivery implant for a single intracameral administration containing 10 mcg of bimatoprost.

AdministrationSingle intracameral (intraocular) administration; one-time per eye as indicated.

Dose vs billingImplant contains 10 mcg total; billed as up to 10 units (1 mcg per unit) using HCPCS code J7351 (1 microgram).

Clinical evidence summaryFDA approval based on phase 3 studies demonstrating IOP reduction non-inferior to timolol.

Eligible diagnoses and basic eligibility

Primary eligible diagnosesOpen angle glaucoma

Background

Durysta is a biodegradable intracameral implant designed for a one‑time administration per eye containing 10 mcg of bimatoprost to reduce intraocular pressure in patients with open angle glaucoma or ocular hypertension. FDA approval was supported by randomized studies demonstrating efficacy versus timolol. The implant is billed in 1 mcg units (HCPCS code J7351), with a documented policy limit of 10 units per eye per lifetime. Coverage is limited to patients meeting clinical criteria (including age ≥18, diagnosis of open angle glaucoma or ocular hypertension, ophthalmologist involvement, prior intolerance/insufficient response to at least two prostaglandin analogs plus one additional IOP‑lowering class, and absence of listed contraindications) and requires prior authorization.