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Table 34: Antibiotics - Ophthalmic


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Drug Category: Ophthalmic

Medication Class/Individual Agents: Antibacterial Agents

I. Prior-Authorization Requirements

 Antibiotics: Ophthalmic

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

azithromycin ophthalmic solution Azasite PA   BP
bacitracin ophthalmic ointment PA   A90
besifloxacin ophthalmic suspension Besivance test  
ciprofloxacin ophthalmic ointment, solution Ciloxan test   # , A90
erythromycin ophthalmic ointment test   A90
gatifloxacin ophthalmic solution Zymaxid test   # , A90
gentamicin ophthalmic ointment, solution test   A90
levofloxacin ophthalmic solution PA   A90
moxifloxacin ophthalmic solution, twice daily PA   A90
moxifloxacin ophthalmic solution-Vigamox Vigamox test   # , A90
natamycin Natacyn test  
ofloxacin ophthalmic solution Ocuflox test   # , A90
sulfacetamide ophthalmic ointment, solution test   A90
tobramycin ophthalmic ointment, solution Tobrex 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.

  • Mild bacterial conjunctivitis may be self-limiting and resolve spontaneously in immune-competent adults.
  • Most ophthalmic antibiotics contain the preservative benzalkonium chloride. Certain patients may have an allergic reaction or experience dose limiting ocular irritation when using agents containing preservatives.  Moxifloxacin ophthalmic solutions are preservative free.
  • Treatment should last five to seven days for bacterial conjunctivitis, five days for corneal ulcers, and a few weeks for blepharitis.
  • Systemic antibiotic treatment should be utilized for conjunctivitis due to Neisseria gonorrhoeae or Chlamydia trachomatis.
  • Ointment may blur vision for up to 20 minutes but are preferred for corneal ulcers because it acts as a lubricant.
  • Contact lens wearers may require a flouroquinolone due to the high incidence of pseudomonas infection.
 

 Antibiotics: Ophthalmic – Combination Products

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

bacitracin / polymyxin B ophthalmic ointment test   A90
gentamicin / prednisolone ophthalmic ointment Pred-G PA  
gentamicin / prednisolone ophthalmic suspension Pred-G test  
neomycin / bacitracin / polymyxin B / hydrocortisone ophthalmic ointment test   A90
neomycin / bacitracin / polymyxin B ophthalmic ointment test   A90
neomycin / polymyxin B / dexamethasone ophthalmic ointment, suspension Maxitrol test   # , A90
neomycin / polymyxin B / gramicidin test   A90
neomycin / polymyxin B / hydrocortisone ophthalmic suspension PA   A90
sulfacetamide / prednisolone sodium phosphate ophthalmic solution test   A90
tobramycin / loteprednol ophthalmic suspension Zylet test  
tobramycin 0.3% / dexamethasone 0.05%, ophthalmic suspension Tobradex ST test  
tobramycin 0.3% / dexamethasone 0.1%, ophthalmic ointment, suspension Tobradex test   # , A90
trimethoprim / polymyxin B ophthalmic solution Polytrim test   # , A90
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.
 
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:

  • Ocular infections involving the conjunctiva and/or cornea
    • bacterial conjunctivitis
    • bacterial keratitis/corneal ulcers
    • blepharitis/blepharoconjunctivitis
    • surgical prophylaxis

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 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.

 

moxifloxacin ophthalmic solution, twice daily

Documentation of the following is required:

  • appropriate diagnosis; and
  • inadequate response or adverse reaction to moxifloxacin ophthalmic solution (Vigamox).

SmartPA: Claims for moxifloxacin ophthalmic solution, twice daily will usually process at the pharmacy without a PA request if the prescriber is an ophthalmologist.

 

Single-entity agents: Azasite, bacitracin ophthalmic ointment, and levofloxacin ophthalmic solution 

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to one or contraindication to all single-entity or combination ophthalmic antibiotic(s) products available without prior authorization.

SmartPA: Claims for levofloxacin ophthalmic solution will usually process at the pharmacy without a PA request if the prescriber is an ophthalmologist.

 

Combination antibiotic/corticosteroid products: neomycin/polymyxin B/hydrocortisone ophthalmic suspension, and Pred-G ointment

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • one of the following: 
      • inadequate response, adverse reaction, or contraindication to an ophthalmic antibiotic/corticosteroid combination product available without prior authorization; or
      • inadequate response, adverse reaction, or contraindication to both a single-entity or combination ophthalmic antibiotic(s) and a single-entity ophthalmic corticosteroid agent available without prior authorization.

 

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: 12/2007

Last Revised Date: 03/2024


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Last updated 06/24/24

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