Prior Authorization — Ophthalmics, Allergic Conjunctivitis
Customize your policy alerts
Sign up for all Pennsylvania Insurance Department policy alerts
Know when Pennsylvania Insurance Department releases new policies or updates existing guidance.
Monitor payer policy activity
Rules for prior authorization of non-preferred ophthalmic products for allergic conjunctivitis for providers and pharmacies enrolled in Pennsylvania Medical Assistance fee-for-service; managed care providers should consult their MCO.
The Department changed the title from 'Ophthalmic Agents for Allergic Conjunctivitis' to 'Ophthalmics, Allergic Conjunctivitis' and clarified that contraindications will be considered when reviewing prior authorization requests for non-preferred products.
Coverage Criteria
Initial prior authorization criteria
Covered when ANY of the following are met:
If the guidelines in Section B are met, the reviewer will prior authorize the prescription; if not met, the request is referred to a physician reviewer who may approve based on professional judgment.
Preferred ophthalmic agents for allergic conjunctivitis listed on the Preferred Drug List (PDL) do not require prior authorization. Only non-preferred Ophthalmic, Allergic Conjunctivitis products require prior authorization. See the PDL at https://papdl.com/preferred-drug-list for the list of preferred agents.
If a request does not meet the clinical review guidelines in Section B (history of therapeutic failure, contraindication, or intolerance to preferred ophthalmics), the request will be referred to a physician reviewer. Requests that do not meet the clinical review guidelines and are not supported by the physician reviewer’s professional judgment will be considered not medically necessary and may be denied.
Provider Actions & Requirements
Prior authorization required for non-preferred ophthalmics
Prescriptions for non-preferred ophthalmic products for allergic conjunctivitis must be prior authorized; reviewers will approve when the beneficiary has a history of therapeutic failure, contraindication, or intolerance to preferred agents, or when a physician reviewer determines the request is medically necessary based on professional judgment.
Step therapy: failure/contraindication/intolerance required
Prior authorization review requires documented evidence the beneficiary has a history of therapeutic failure, contraindication, or intolerance to preferred ophthalmic agents before a non-preferred product will be approved; if these clinical guidelines are not met the request is escalated to a physician reviewer who may still approve based on professional judgment.
- Evidence must demonstrate therapeutic failure, a contraindication, or intolerance to preferred Ophthalmics, Allergic Conjunctivitis.
- If guidelines are not met, the request is referred to a physician reviewer for a medical necessity determination.
Follow handbook procedures and submit supporting documentation
Providers must follow the procedures in SECTION I of the Prior Authorization of Pharmaceutical Services Handbook and submit documentation demonstrating history of therapeutic failure, contraindication, or intolerance to preferred ophthalmic agents as described in the clinical review guidelines.
- Use the handbook procedures to ensure appropriate and timely processing of prior authorization requests (55 Pa. Code § 1101.67(a)).
- Submit documentation that supports the clinical criteria in Section B (history of failure, contraindication, or intolerance).
Denial risk if clinical criteria not met
Requests for non-preferred ophthalmics may be denied when the clinical review guidelines (history of therapeutic failure, contraindication, or intolerance to preferred agents) are not met and a physician reviewer does not determine the service is medically necessary.
- If Section B clinical guidelines are met the reviewer will authorize; if not met and physician reviewer does not find medical necessity, the request may be denied.
Initial Therapy Criteria
Initial therapy
Prior authorization for non-preferred agents requires evidence of failure, intolerance, or contraindication to preferred agents.
If clinical review guidelines are not met, the request will be referred to a physician reviewer for a medical necessity determination.
Step Therapy Requirements
| Step | Requirement | Notes |
|---|---|---|
| 1 | Evidence of therapeutic failure, contraindication, or intolerance to preferred Ophthalmics for Allergic Conjunctivitis is required before approving a non-preferred product. | If the beneficiary does not meet these clinical review guidelines, a physician reviewer may still approve the request based on professional judgment. |
Definitions
Background
This bulletin updates handbook pages governing prior authorization for ophthalmic treatments for allergic conjunctivitis and clarifies that non-preferred Ophthalmic, Allergic Conjunctivitis products must be prior authorized. It also specifies that reviewers will consider history of therapeutic failure, contraindication, or intolerance to preferred ophthalmics when evaluating requests, and that a physician reviewer may approve a request based on professional judgment even if the clinical guidelines are not met.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.