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Table 51: Antiglaucoma Agents - Ophthalmic


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Drug Category: Ophthalmic

Medication Class/Individual Agents: Antiglaucoma Agents

I. Prior-Authorization Requirements

 Antiglaucoma Agents: Ophthalmic – Alpha-Adrenergic Agents

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

apraclonidine Iopidine test   # , M90
brimonidine 0.1%, 0.15% eye drops Alphagan P test   BP, M90
brimonidine 0.2% eye drops test   M90

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.

  • Patients diagnosed with ocular hypertension or suspected open-angle glaucoma should be offered medication based on the risk factors for developing primary open-angle glaucoma such as high intraocular pressure (IOP), type 2 diabetes mellitus, and older age.1
  • Ophthalmic prostaglandin analogues are often considered first-line. If target IOP has not been achieved, switching to an alternative medication or adding additional medication (e.g., ophthalmic beta-blockers, alpha-2 adrenergic agonists, carbonic anhydrase inhibitors, parasympathomimetics) is recommended.2

Gedde SJ, Lind JT, Wright MM, Chen PP, Muir KW, Vinod K, et al. Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern Guidelines. Ophthalmology. 2020 Nov; 128(1):P151-192.

2 Gedde SJ, Vinod K, Wright MM, Muir KW, Lind JT, Chen PP, et al. Primary Open-Angle Glaucoma Preferred Practice Pattern Guidelines. Ophthalmology. 2020 Nov;128(1):P71-P150.

 

 Antiglaucoma Agents: Ophthalmic – Beta-Adrenergic Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

betaxolol 0.25% Betoptic S test  
betaxolol 0.5% test   M90
carteolol test   M90
levobunolol test   M90
timolol ophthalmic gel forming solution Timoptic-XE PA   M90
timolol ophthalmic unit dose solution Timoptic Ocudose PA   BP, M90
timolol-Betimol Betimol PA  
timolol-Istalol Istalol test   BP, M90
timolol-Timoptic Timoptic test   # , M90

 Antiglaucoma Agents: Ophthalmic – Carbonic Anhydrase Inhibitors

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

brinzolamide Azopt test   BP, M90
dorzolamide Trusopt test   # , M90

 Antiglaucoma Agents: Ophthalmic – Combination Products

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

brimonidine / timolol, ophthalmic Combigan PA   M90
brinzolamide / brimonidine Simbrinza test  
dorzolamide / timolol Cosopt test   # , M90
dorzolamide / timolol, preservative free Cosopt PF PA   BP, M90
netarsudil / latanoprost Rocklatan PA  

 Antiglaucoma Agents: Ophthalmic – Miotics

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

acetylcholine chloride Miochol-E test   MB
carbachol 0.01% Miostat test   MB
echothiophate iodide Phospholine Iodide test  
pilocarpine 1%, 2%, 4% ophthalmic solution Isopto Carpine test   # , M90

 Antiglaucoma Agents: Ophthalmic – Prostaglandins

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

bimatoprost 0.01% ophthalmic solution Lumigan test  
bimatoprost 0.03% ophthalmic solution PA   M90
bimatoprost implant Durysta PA   MB
latanoprost emulsion Xelpros PA  
latanoprost solution - Iyuzeh Iyuzeh PA  
latanoprost solution - Xalatan Xalatan test   # , M90
latanoprostene Vyzulta PA  
tafluprost Zioptan PA   BP, M90
travoprost 0.004% eye drop Travatan Z test   BP, M90

 Antiglaucoma Agents: Ophthalmic – Rho Kinase Inhibitor

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

netarsudil Rhopressa PA  
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. PA 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.
 
MB This drug is available through the health care professional who administers the drug or in an outpatient or inpatient hospital setting. MassHealth does not pay for this drug to be dispensed through the retail pharmacy. If listed, PA does not apply through the hospital outpatient and inpatient settings. Please refer to 130 CMR 433.408 for PA requirements for other health care professionals. Notwithstanding the above, this drug may be an exception to the unified pharmacy policy; please refer to respective MassHealth Accountable Care Partnership Plans (ACPPs) and Managed Care Organizations (MCOs) for PA status and criteria, if applicable.
 
M90 Mandatory 90-day supply. After dispensing up to a 30-day supply initial fill, dispensing in a 90-day supply is required. May not include all strengths or formulations. Quantity limits and other restrictions may also apply.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Ocular hypertension
  • Open-angle glaucoma

Non-FDA-approved, for example:

  • infantile hemangioma

Note: The above lists may not include all FDA-approved and non-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 diagnosis and/or requested medication (see below). Other factors, including rebate and FDA-approval status, may change independently of scheduled MassHealth updates, which may result in additional restrictions.

 

Betimol

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to an ophthalmic timolol product available without PA.

SmartPA: Claims for Betimol will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for an ophthalmic timolol product that is available without PA.†

     

bimatoprost 0.03% ophthalmic solution

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to one or contraindication to both of the following: latanoprost solution, travoprost 0.004% eye drop.

      

brimonidine/timolol, ophthalmic

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to dorzolamide/timolol.

 

dorzolamide/timolol preservative free and Xelpros

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • sensitivity to benzalkonium chloride or any other preservative used in ophthalmic preparations.

    

Durysta

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • one of the following:
      • inadequate response or adverse reaction to Lumigan; or
      • medical necessity for the use of an implantable formulation as noted by one of the following:
        • limited dexterity; or
        • visual impairment; or
        • intellectual disability; and
    • affected eye(s) have not previously been treated with Durysta.

    

Iyuzeh and tafluprost

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to Xelpros; and
    • one of the following:
      • inadequate response, adverse reaction or contraindication to latanoprost solution available without PA; or
      • sensitivity to benzalkonium chloride or any other preservative used in ophthalmic preparations.

SmartPA: Claims for Iyuzeh or tafluprost will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for latanoprost solution available without PA and Xelpros.†

   

Rhopressa

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • one of the following:
      • inadequate response to combination therapy with a prostaglandin analog and an ophthalmic beta-blocker; or
      • contraindication or adverse reaction to prostaglandin analogs and ophthalmic beta-blockers; or
      • both of the following:
        • contraindication to ophthalmic beta-blockers; and
        • inadequate response or adverse reaction to a prostaglandin analog in combination with one of the following: ophthalmic alpha-2 adrenergic agonist, parasympathomimetic, carbonic anhydrase inhibitor; or
      • both of the following:
        • contraindication to prostaglandin analogs; and
        • inadequate response or adverse reaction to an ophthalmic beta-blocker in combination with one of the following: ophthalmic alpha-2 adrenergic agonist, parasympathomimetic, carbonic anhydrase inhibitor.

 

Rocklatan

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • one of the following:
      • inadequate response to combination therapy with a prostaglandin analog and an ophthalmic beta-blocker; or
      • both of the following:
        • contraindication to ophthalmic beta-blockers; and
        • inadequate response or adverse reaction to a prostaglandin analog in combination with one of the following: ophthalmic alpha-2 adrenergic agonist, parasympathomimetic, carbonic anhydrase inhibitor.

      

timolol ophthalmic gel forming solution

  • Documentation of the following is required for diagnosis of ocular hypertesion or open-angle glaucoma:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to an ophthalmic timolol-containing product available without PA.
  • Documentation of the following is required for diagnosis of infantile hemangioma: 
    • appropriate diagnosis.

SmartPA: Claims for timolol ophthalmic gel forming solution will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for an ophthalmic timolol-containing product.†

 

timolol ophthalmic unit dose solution

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • one of the following:
      • inadequate response or adverse reaction to an ophthalmic timolol product available without PA; or 
      • sensitivity to benzalkonium chloride.

SmartPA: Claims for timolol ophthalmic unit dose solution will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for an ophthalmic timolol product that is available without a PA.†

     

Vyzulta

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 17 years of age; and
    • one of the following:
      • inadequate response to combination therapy with latanoprost solution and an ophthalmic beta-blocker; or
      • both of the following:
        • inadequate response to latanoprost solution; and
        • contraindication or adverse reaction to an ophthalmic beta-blocker.

 

† 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: 11/2010

Last Revised Date: 05/2024


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Last updated 05/16/24

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