CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Cyclosporine ophthalmic emulsion 0.05% coverage criteria

Policy governing coverage and prior authorization requirements for cyclosporine ophthalmic emulsion 0.05% for members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCyclosporine ophthalmic emulsion 0.05% coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2020

Next Review Date

Key ActionObtain documentation that the member trialed and experienced inadequate response or intolerance to formulary artificial tears before prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthscoverage duration per approval

trial requiredstep therapy prerequisite

365 dayslookback period

Coverage Criteria

Initial coverage criteria

Covered when ALL of the following are met

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Neighborhood Health Plan of Rhode Island does not provide coverage for drugs when used for investigational purposes. Therapies are considered investigational when they are used at a dose or for a condition that is not recognized as a medically accepted indication by standard reference compendia (AHFS-DI, Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi-Drugs) or by peer-reviewed published medical literature demonstrating sufficient evidence to support the use. Such uses are not covered under this policy.

Coding and Lookback

Referenced productsmixed

No codes listed

Coding threshold — lookback period

Lookback period for prior paid claim365 days

Applies to step-therapy coding logicAt least one paid claim within the last 365 days for formulary artificial tears or cyclosporine ophthalmic emulsion 0.05% satisfies the step-therapy requirement

PurposeUsed to demonstrate prior trial of formulary artificial tears for prior authorization and step-therapy determination

Provider Action Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required: The member must have trialed and experienced an inadequate treatment response or intolerance to formulary artificial tears prior to coverage of cyclosporine ophthalmic emulsion 0.05%.

Formulary artificial tears trial and documentation required

Step Therapy

Step Therapy Requirement

Step therapy: A paid claim within the last 365 days for formulary artificial tears (or a paid claim for cyclosporine ophthalmic emulsion 0.05% itself) is required for approval.

Paid claim within last 365 days for formulary artificial tears or cyclosporine 0.05%

Documentation Required

Required Clinical Documentation

Required clinical documentation: Submit evidence of trial and inadequate response or intolerance to formulary artificial tears and documentation of the paid claim(s) (dates and agents) demonstrating the step-therapy prerequisite has been met. Coverage duration when approved: 12 months.

Documentation of trial and inadequate response or intolerance to formulary artificial tears (dates, agent, clinical outcome)
Proof of paid claim(s) within last 365 days (date of service, drug name)

Denial Risk

Denial Risk if Prerequisites Missing

If documentation of the required trial or paid claim is missing, the prior authorization may be denied or fail. Investigational uses are not covered — therapies used outside recognized indications or dosing per standard compendia are considered investigational and will be denied.

Absence of trial or paid claim documentation may lead to denial
Investigational indications or non-standard dosing not covered

Background

Cyclosporine ophthalmic emulsion 0.05% is indicated in this policy as a topical ophthalmic anti-inflammatory therapy for ocular surface disease when coverage criteria are met. Prior authorization requires documentation that the member has trialed and experienced an inadequate treatment response or intolerance to formulary artificial tears. Approval, when granted, is issued for 12 months.

For step-therapy verification, the policy will accept evidence of at least one paid claim within the prior 365 days for formulary artificial tears or for cyclosporine ophthalmic emulsion 0.05% itself to demonstrate that the step-therapy prerequisite has been met.

Definitions

Definition — investigational use

Investigational use — definitionTherapies are considered investigational when used at a dose or for a condition other than those recognized as medically accepted indications per standard reference compendia (AHFS-DI, Micromedex DrugDex, Clinical Pharmacology, Lexi-Drugs) or peer-reviewed literature.

Implication for coverageNeighborhood does not provide coverage for drugs when used for investigational purposes.

Acceptable referencesAmerican Hospital Formulary Service Drug information (AHFS-DI), Thomson Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi-Drugs, or peer-reviewed published medical literature.

ScopeApplies to use at non‑recognized doses or for conditions not supported by the listed compendia or literature.