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Table 29: Anti-Allergy and Anti-Inflammatory Agents - Ophthalmic


A    B    C    D    E    F    G    H    I    J    K    L    M    N    O    P    Q    R    S    T    U    V    W    X    Y    Z


Drug Category: Anti-Allergy and Anti-Inflammatory Agents - Ophthalmic

Medication Class/Individual Agents: Anti-Allergy and Anti-Inflammatory Agents - Ophthalmic

I. Prior-Authorization Requirements

 Ophthalmic Anti-Allergy and Anti-Inflammatory Agents – Antihistamines

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

alcaftadine Lastacaft test  
bepotastine Bepreve test   BP, A90
cetirizine ophthalmic solution Zerviate PA  
ketotifen test   *, A90

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • Nonpharmacologic treatments, such as allergen avoidance, cold compress, and lubrication to remove the allergen, may provide relief.
  • Products containing vasoconstrictors may cause rebound redness if used more frequently than the recommended treatment duration.
  • The dropper tip should not touch the eye in order to prevent contaminating the bottle.
  • Remove contact lenses before instilling eye drops as some preservatives in ocular products may be absorbed by soft contact lenses.
  • FDA-approved ages:
    •  18 years of age: bromfenac, cyclosporine 0.09%, dexamethasone, diclofenac, difluprednate, flurbiprofen, hydroxypropyl cellulose ophthalmic insert, loteprednol, prednisolone
    •  17 years of age: lifitegrast
    •  16 years of age: cyclosporine 0.05%
    •  ten years of age: nepafenac
    •  three years of age: azelastine, ketotifen, ketorolac tromethamine 0.4%, nedocromil
    •  two years of age: alcaftadine, bepotastine, cetirizine, epinastine, fluorometholone, ketorolac tromethamine 0.5%, lodoxamide, olopatadine

Pregnancy:

alcaftadine, cetirizine, lodoxamide, and nedocromil are pregnancy category B; the rest of the ophthalmic anti-allergy agents are pregnancy category C.

 

 Ophthalmic Anti-Allergy and Anti-Inflammatory Agents – Corticosteroids

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

dexamethasone intravitreal implant Ozurdex test   ^
dexamethasone ophthalmic insert Dextenza test   ^
dexamethasone ophthalmic suspension Maxidex test  
dexamethasone sodium phosphate ophthalmic solution test   A90
difluprednate Durezol test   BP
fluorometholone FML test   # , A90
fluorometholone acetate Flarex test  
loteprednol 0.2% Alrex test  
loteprednol 0.25% suspension Eysuvis PA  
loteprednol 0.38% gel Lotemax SM PA  
loteprednol 0.5% Lotemax test   BP, A90
loteprednol 1% suspension Inveltys PA  
prednisolone acetate 0.12% ophthalmic suspension Pred Mild test  
prednisolone acetate 1% ophthalmic suspension Pred Forte test   # , A90
prednisolone acetate 1% ophthalmic suspension test   A90
prednisolone sodium phosphate ophthalmic solution test   A90

 Ophthalmic Anti-Allergy and Anti-Inflammatory Agents – Mast Cell Stabilizer /Antihistamine

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

azelastine ophthalmic solution test   A90
epinastine PA   A90
olopatadine ophthalmic solution test   A90

 Ophthalmic Anti-Allergy and Anti-Inflammatory Agents – Mast Cell Stabilizers

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

cromolyn ophthalmic test   A90
lodoxamide Alomide test  
nedocromil Alocril test  

 Ophthalmic Anti-Allergy and Anti-Inflammatory Agents – NSAIDs

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

bromfenac 0.07% Prolensa test   BP
bromfenac 0.075% Bromsite PA  
bromfenac 0.09% PA   A90
diclofenac ophthalmic solution test   A90
flurbiprofen ophthalmic solution test   A90
ketorolac 0.4% ophthalmic solution Acular LS test   # , A90
ketorolac 0.45% ophthalmic solution Acuvail test  
ketorolac 0.5% ophthalmic solution Acular test   # , A90
nepafenac 0.1% ophthalmic suspension Nevanac test  
nepafenac 0.3% ophthalmic suspension Ilevro PA  

 Ophthalmic Anti-Allergy and Anti-Inflammatory Agents – Not Otherwise Classified

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

artificial tears test   *, A90
cyclosporine 0.05% ophthalmic emulsion Restasis test   BP, A90
cyclosporine 0.09% ophthalmic solution Cequa PA  
cyclosporine multidose 0.05% ophthalmic emulsion Restasis Multidose PA  
hydroxypropyl cellulose ophthalmic insert Lacrisert test  
lifitegrast Xiidra PA  
naphazoline test   *
naphazoline / pheniramine Naphcon-A test   A90
naphazoline / pheniramine Opcon-A test   A90
varenicline nasal spray Tyrvaya PA  
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization.
 
^ This drug is available through the health care professional who administers the drug. MassHealth does not pay for this drug to be dispensed through a retail pharmacy.
 
A90 Allowable 90-day supply. Dispensing in up to a 90-day supply is allowed. May not include all strengths or formulations. Quantity limits and other restrictions may apply.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Perennial (chronic) or seasonal (short term) allergic conjunctivitis (epinastine, Zerviate)
  • Postoperative pain and inflammation following ocular surgery (bromfenac 0.09%, Bromsite, Ilevro, Inveltys, Lotemax SM)
  • Keratoconjunctivitis sicca (KCS)/dry eyes (Cequa, Eysuvis, Restasis Multidose, Tyrvaya, Xiidra)

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency. 
  • Dispensing in a 90-day supply of medication may be mandated or allowable for agents in this therapeutic class (designated by M90 or A90, respectively, in the Drug Notes section above). Applicable quantity limits are described below as units per day, per month, per 28 days, or as clinically appropriate, and may be extrapolated for fills of longer day supply. 
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply depending upon requested medication (see below).   

 

bromfenac 0.09% and Bromsite

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • an inadequate response or adverse reaction to Prolensa.

 

Cequa

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • an inadequate response or adverse reaction to cyclosporine 0.05% ophthalmic emulsion; and
    • requested quantity is for ≤ two units/day.

SmartPA: Claims for Cequa will usually process at the pharmacy for a quantity of ≤ two units/day if the member is ≥ 18 years of age and there is a history of paid claims for 90 out of 120 days for Cequa or if there is a history of paid claims for cyclosporine 0.05% ophthalmic solution in the most recent 90 days.

 

epinastine for members ≥ three years of age

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: azelastine ophthalmic solution, bepotastine, ketotifen, Lastacaft, olopatadine ophthalmic solution.

 

epinastine for members ≥ two to < three years of age

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: bepotastine, ketotifen, olopatadine ophthalmic solution.

 

Eysuvis

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • an inadequate response or adverse reaction to one topical corticosteroid for ophthalmic use available without prior authorization, or contraindication to all topical corticosteroids for ophthalmic use available without prior authorization; and
    • an inadequate response, adverse reaction, or contraindication to cyclosporine 0.05% ophthalmic emulsion; and
    • requested duration is ≤ two weeks.

 

Ilevro

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • member is ≥ ten years of age; and
    • an inadequate response or adverse reaction to nepafenac 0.1% ophthalmic suspension.

 

Inveltys and Lotemax SM (for postoperative pain and inflammation)

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • an inadequate response or adverse reaction to loteprednol 0.5% ophthalmic gel, ointment, or suspension.

 

Restasis Multidose

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • member is ≥ 16 years of age; and
    • medical necessity for use of this formulation instead of cyclosporine 0.05% ophthalmic emulsion (single use vial formulation); and
    • requested quantity is for ≤ 1 unit/28 days.

 

Tyrvaya

  • Documentation of the following is required: 
    • an appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • an inadequate response, adverse reaction, or contraindication to both of the following: cyclosporine 0.05% ophthalmic emulsion and Xiidra; and
    • requested quantity is for ≤ 8.4 mL/30 days.

 

Xiidra

  • Documentation of the following is required: 
    • an appropriate diagnosis; and
    • member is ≥ 17 years of age; and
    • an inadequate response, adverse reaction, or contraindication to cyclosporine 0.05% ophthalmic emulsion; and
    • requested quantity is for ≤ two units/day.

SmartPA: Claims for Xiidra will usually process at the pharmacy for a quantity of ≤ two units/day if the member is ≥ 17 years of age and there is a history of paid claims for 90 out of 120 days for Xiidra or if there is a history of paid claims for cyclosporine 0.05% ophthalmic solution in the most recent 90 days.

 

Zerviate for members ≥ three years of age

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • an inadequate response or adverse reaction to two or contraindication to all of the following: Alocril, Alomide, azelastine ophthalmic solution, bepotastine, ketotifen, Lastacaft, olopatadine ophthalmic solution; and
    • an inadequate response, adverse reaction, or contraindication to epinastine.

 

Zerviate for members ≥ two to < three years of age

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • an inadequate response or adverse reaction to two or contraindication to all of the following: Alomide, bepotastine, epinastine, Lastacaft, olopatadine ophthalmic solution.

Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.


Original Effective Date: 04/2005

Last Revised Date: 09/2022


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Last updated 09/19/22

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