CurrentNeighborhood Health Plan of Rhode IslandPolicy 613-D

Initial Step Therapy; Post Step Therapy Prior Authorization — Prostaglandin Analogues and Combinations

Defines initial step therapy and prior authorization requirements for branded prostaglandin analogue ophthalmic agents for members whose prescription benefits are administered by CVS Caremark. Applies to requests for branded prostaglandin products when generic step therapy options exist.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyInitial Step Therapy; Post Step Therapy Prior Authorization — Prostaglandin Analogues and Combinations

Policy CodePolicy 613-D

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization if the member has not filled at least a 30-day supply of a generic prostaglandin analogue within the past 730 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 monthsDuration of approval

730 daysLookback

30 daysMin trial

Coverage Criteria

Authorization criteria

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Authorization criteria: The patient has experienced an inadequate treatment response after at least a 30 day trial of at least ONE generic prostaglandin analogue drug.30 days trial

Supports approval of branded product if inadequate response to generic.

Authorization criteria: The patient has a documented contraindication or a potential drug interaction that would prohibit a trial of at least ONE generic prostaglandin analogue drug.documented contraindication or interaction

Allows bypass of the generic trial requirement.

Authorization criteria: The patient has experienced an intolerance to at least ONE generic prostaglandin analogue drug.documented intolerance

Allows bypass of the generic trial requirement.

Products and Coding

Products referencedmixed

Iyuzeh	Brand name listed in products referenced
Lumigan	Brand name listed in products referenced
Rocklatan	Brand name listed in products referenced
Vyzulta	Brand name listed in products referenced
Xelpros	Brand name listed in products referenced

inv-04: Generic trial requirement — >= 30 day supply within past 730 days.

RequirementMember must have filled at least a 30‑day supply of one generic prostaglandin analogue within the past 730 days to meet initial step therapy.

Lookback period730 days (from date of request)

Minimum trial duration30 days supply of a generic prostaglandin analogue

When not metIf the initial step is not met the claim will reject with a message indicating a prior authorization is required.

PA next stepRequests that do not meet step therapy must be submitted to the PA unit for evaluation per prior authorization criteria.

Provider Actions / Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required when the member has not met the step-therapy requirement. If the member has not filled at least a 30-day supply of a generic prostaglandin analogue within the past 730 days, the claim will reject with a message indicating that a prior authorization (PA) is required; PA criteria must be submitted to and reviewed by the PA unit.

Claim rejection message: prior authorization required when initial step not met
PA requests submitted to PA unit for review

Step Therapy

Initial Step Therapy Requirements

Initial step therapy requirement: member must have filled at least a 30-day supply of at least one generic prostaglandin analogue within the past 730 days under the prescription benefit administered by CVS Caremark. If this initial step is met, the requested branded drug will be paid under that prescription benefit.

Initial step: ≥30-day supply of ≥1 generic prostaglandin analogue within the past 730 days
Benefit administered by CVS Caremark

Documentation Required

Required Supporting Documentation

Documentation must be provided to support any of the following exceptions to step therapy: inadequate response, documented contraindication or potential drug interaction that precludes trial, or intolerance to at least one generic prostaglandin analogue.

Documentation of inadequate response to ≥30-day trial of ≥1 generic prostaglandin analogue
Documentation of a contraindication or clinically significant drug interaction preventing trial
Documentation of intolerance to ≥1 generic prostaglandin analogue

Background

Prostaglandin analogues are topical ophthalmic agents commonly used to lower intraocular pressure in glaucoma and ocular hypertension. Branded prostaglandin analogue products are subject to step therapy: authorization for a requested branded prostaglandin is granted when ONE of the following is documented — (1) an inadequate treatment response after at least a 30 day trial of at least ONE generic prostaglandin analogue, (2) a documented contraindication or potential drug interaction preventing a generic trial, or (3) a documented intolerance to at least ONE generic prostaglandin analogue.

Definitions

inv-10: GSTP — Generic Step Therapy Plans, the program referenced for prostaglandin analogues and combinations.

DefinitionGSTP (Generic Step Therapy Plans) — the program referenced for prostaglandin analogues and combination products.

ScopeApplies to prostaglandin analogues and combination ophthalmic products subject to step therapy and PA rules.

PurposeEstablishes required trial of generic prostaglandin agents before coverage of requested branded product unless criteria for bypass are met.

Related policy referencePolicy number 613‑D applies to GSTP prostaglandin analogues & combos.