CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

iDose TR

Defines medical-benefit coverage and prior authorization criteria for iDose TR (travoprost intracameral implant) for Medicaid, Commercial, and Medicare members of Neighborhood Health Plan of Rhode Island, including clinical eligibility, contraindications, dosing limits, billing code, and documentation expectations.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyiDose TR

Policy CodePolicy N/A

Change TypeClarified review/effective dates

Effective DateSep 1, 2024

Next Review DateMay 7, 2026

Key ActionSubmit prior authorization requests meeting all specified clinical criteria and provide required clinical documentation to support approval.

SourceLink

POLICY UPDATE CHANGES

Policy effective date set to 09/01/2024 and review dates recorded (07/17/2024, 05/07/2025, 01/27/2026).

1Implants allowed per eye

>=18Minimum age (years)

2+Required prior prostaglandin analogs tried

75 mcgImplant drug content (travoprost)

Coverage Summary

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Coverage stance: covered_with_criteria for iDose TR (travoprost intracameral implant) when used according to the policy's clinical criteria. Scope: Medical-benefit coverage for Medicaid, Commercial, and Medicare members of Neighborhood Health Plan of Rhode Island, intended to support safe, effective, and appropriate use of iDose TR to reduce intraocular pressure in adults with open angle glaucoma or ocular hypertension. Effective date: 09/01/2024. Next review date: 05/07/2026. Last review: 01/27/2026.

Key Limits & Thresholds

Minimum age>= 18 years

Lifetime implants per eye1 implant per eye per lifetime

Maximum billable units per eye75 units (1 unit = 1 microgram; implant contains 75 mcg travoprost) per eye per lifetime

Initial Therapy Criteria

Initial Therapy

Covered when ALL of the following are met:

ALL of the following

Member is 18 years of age or older
Member has a diagnosis of open angle glaucoma or ocular hypertension
iDose TR (travoprost) has been prescribed by or in consultation with an ophthalmologist
Intolerance or an insufficient response to at least two ophthalmic prostaglandin analogs 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
NONE of the following contraindications
- Active or suspected ocular or periocular infection
- Diagnosis of corneal endothelial cell dystrophy (e.g., Fuchs' Dystrophy)
- History of corneal transplantation or endothelial cell transplant (e.g., Descemet's Stripping Automated Endothelial Keratoplasty [DSAEK])
- Absent or ruptured posterior lens capsule
- Hypersensitivity to travoprost or to any other component of iDose TR (travoprost)
The affected eye has not received prior treatment with iDose TR (travoprost)
The member will not concurrently use iDose TR (travoprost intracameral implant) with Durysta (bimatoprost intracameral implant)
Medicare members who have previously received this medication within the past 365 days are not subject to Step Therapy Requirements

Coverage Duration / Frequency

ALL of the following

Coverage will be provided for one implant per eye per lifetime and may not be renewed

Billing Rule

Billing Units and Dose Conversion

1 billable unit = 1 microgram. The intracameral implant contains 75 mcg travoprost. Maximum billable quantity is 75 units per eye per lifetime. Applicable billing code: J7355.

J7355 — Injection, travoprost, intracameral implant, 1 microgram
Unit conversion: 1 billable unit = 1 microgram; implant contains 75 mcg travoprost; maximum 75 units per eye per lifetime

Provider Actions & Documentation

Prior Authorization

Prior Authorization Required

Coverage of iDose TR will be reviewed prospectively via the prior authorization process and requests must meet all specified clinical criteria. Submission of billing or procedure codes does not guarantee coverage.

Documentation Required

Clinical Documentation to Support Initial Criteria

Required documentation to support initial coverage: age (≥18 years); diagnosis of open angle glaucoma or ocular hypertension; prescription by or consult with an ophthalmologist; documentation of intolerance or insufficient response to at least two ophthalmic prostaglandin analogs AND at least one other IOP-reducing ophthalmic product from a different class; documentation that none of the listed contraindications are present; and confirmation the affected eye has not previously received iDose TR.

Age (≥18 years)
Diagnosis: open angle glaucoma (OAG) or ocular hypertension (OHT)
Prescription or consult from an ophthalmologist
Intolerance or insufficient response to ≥2 prostaglandin analogs AND ≥1 other IOP-lowering class
Absence of listed contraindications (e.g., active ocular infection, corneal endothelial dystrophy, prior corneal transplant, absent/ruptured posterior lens capsule, hypersensitivity to travoprost)
Confirmation the affected eye has not previously received iDose TR

Denial Risk

Non-payment Risk for Use Outside Guidelines

Use of iDose TR outside the listed guidelines may result in non-payment unless an exception is approved.

Clinical Evidence

Evidence summary: Two multicenter, 12-month, randomized, double-masked, active-controlled trials (total n=1,150) compared iDose TR to twice-daily topical timolol 0.5%. In the first 3 months, iDose TR produced mean IOP reductions from baseline of -6.6 to -8.4 mmHg (mean baseline ~24 mmHg) and demonstrated non-inferiority to timolol during months 1–3. iDose TR did not demonstrate non-inferiority to timolol during months 4–12. FDA prescribing information for iDose TR (Glaukos, December 2023) is cited as the reference for these trial results.

1,150Trial sample size (two 12-month randomized trials)

-6.6 to -8.4Observed IOP change from baseline (first 3 months), mmHg

12-monthTrial duration (length of randomized studies)

Background & Definitions

Background and safety: iDose TR is a travoprost intracameral implant indicated to reduce intraocular pressure in patients with open angle glaucoma or ocular hypertension. Clinical trial findings showed IOP reductions with non-inferiority to timolol in the first 3 months but not over months 4–12. Key adverse events and safety concerns include increases in intraocular pressure, iritis, dry eye, visual field defects, risk of device dislocation, and potentially permanent increased pigmentation of the iris. The implant is supplied as a single-dose intracameral inserter containing 75 mcg travoprost and should not be readministered to an eye that previously received iDose TR.

Term	Definition
IOP	Intraocular pressure
OAG	Open angle glaucoma
OHT	Ocular hypertension
DSAEK	Descemet's Stripping Automated Endothelial Keratoplasty

Revision History

2024-09-01effective_date

Policy effective date set to 09/01/2024.

2024-07-17review_date

Review date recorded: 07/17/2024.

2025-05-07review_date

Review date recorded: 05/07/2025.

2026-01-27review_dateLatest

Review date recorded: 01/27/2026.