CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Travoprost 0.004% & Tafluprost 0.0015% ophthalmic solution

Coverage policy for travoprost 0.004% and tafluprost 0.0015% ophthalmic solutions for members, specifying required prior trial with formulary latanoprost and quantity/duration limits. Applies to pharmacy/drug benefit decisions for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTravoprost 0.004% & Tafluprost 0.0015% ophthalmic solution

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain and document at least one paid claim for formulary latanoprost 0.005% within the prior 365 days and evidence of inadequate response or intolerance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1required prior trial

0.1 ml/dayquantity limit

12 mocoverage duration

365 dayslookback

Coverage Criteria

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Prior trial and response: Member has trialed and experienced an inadequate treatment response or intolerance to formulary latanoprost 0.005% ophthalmic solution.>= 1 paid claim within the prior 365 days

Documentation required of inadequate response or intolerance to latanoprost.

Quantity limit: Prescribed quantity does not exceed 0.1 ml per day.0.1 ml/day

Coverage duration limited to 12 months.

Coverage duration is up to 12 months per authorization.12 months

Reauthorization requirements not specified in source document.

Neighborhood Health Plan of Rhode Island does not provide coverage for drugs used for investigational purposes. Therapies are considered investigational when used at doses or for conditions other than those recognized as medically accepted indications in standard reference compendia or peer‑reviewed literature. Examples of accepted compendia include AHFS‑DI, Micromedex DrugDex, Clinical Pharmacology, and Lexi‑Drugs.

Additionally, coverage for travoprost 0.004% and tafluprost 0.0015% ophthalmic solution is subject to the policy's clinical criteria; uses or dosing outside those specified criteria (including investigational indications or non‑covered doses) will not be approved.

Covered Drugs and Coding Logic

Covered drugs / Step agentsmixedCovered

travoprost 0.004% ophthalmic solution	Drug name as listed in policy
tafluprost 0.0015% ophthalmic solution	Drug name as listed in policy
latanoprost 0.005% ophthalmic solution	Formulary comparator required for prior trial

Prior claim lookback

Lookback period>= 1 paid claim for formulary latanoprost 0.005% within the last 365 days

PurposeEstablish prior trial of formulary latanoprost before coverage of travoprost or tafluprost

Evidence acceptedPaid pharmacy claim for latanoprost 0.005% within 365 days documented in claims history

Quantity limit

Daily quantity limit0.1 ml per day

ApplicationApplies to travoprost 0.004% and tafluprost 0.0015% authorizations

Coverage noteQuantity limit enforced for coverage duration up to 12 months

Provider Actions & Authorization Requirements

Prior Authorization

Step therapy prerequisite — paid latanoprost claim required

Prior authorization requires evidence of at least one paid claim for formulary latanoprost 0.005% within the prior 365 days and documentation of inadequate response or intolerance to that agent.

Lookback period: 365 days for paid latanoprost 0.005% claim

Step Therapy

Step therapy requirement — trial and inadequate response/intolerance to latanoprost

Travoprost 0.004% or tafluprost 0.0015% will be approved only after a trial demonstrating inadequate therapeutic response or intolerance to formulary latanoprost 0.005%.

Approval contingent on prior trial and documented inadequate response or intolerance to latanoprost 0.005%

Documentation Required

Required medical information — document prior latanoprost trial and outcome

Documentation must show a trial of formulary latanoprost 0.005% ophthalmic solution and evidence of inadequate treatment response or intolerance.

Record the trial of latanoprost 0.005% and clinical notes describing inadequate IOP control or adverse effects necessitating change

Denial Risk

Prior trial required — risk of denial for missing documentation

Lack of documentation of a prior trial and inadequate response or intolerance to formulary latanoprost 0.005% within the past 365 days may result in claim denial.

Ensure submitted records include evidence of >=1 paid latanoprost 0.005% claim within 365 days and notes of inadequate response or intolerance

Definitions

Inadequate treatment response or intolerance

DefinitionProvider-documented insufficient therapeutic effect or adverse effect/intolerance to formulary latanoprost 0.005% necessitating change in therapy

Required documentationMedical record notes describing inadequate intraocular pressure control or adverse reaction to latanoprost 0.005%

Role in step therapyMust be documented to approve travoprost 0.004% or tafluprost 0.0015% after prior latanoprost trial

Background

Travoprost 0.004% and tafluprost 0.0015% are prostaglandin analogue ophthalmic solutions indicated to lower intraocular pressure in glaucoma or ocular hypertension. Coverage under this policy requires documentation that the member has trialed and experienced an inadequate treatment response or intolerance to formulary latanoprost 0.005% ophthalmic solution.

When authorized, use is limited by a quantity limit of 0.1 ml per day and a coverage duration of up to 12 months. Approval also follows the policy's step‑therapy coding logic: travoprost or tafluprost will be covered only if there is at least one paid claim for formulary latanoprost 0.005% within the prior 365 days documenting the required trial.