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Ophthalmic Prostaglandin Analogs

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Ophthalmic Prostaglandin Analogs Drug and Biologic Coverage Policy Effective Date ............................................ 6/1/2021 Next Review Date… ..................................... 6/1/2022 Coverage Policy Number ............................... IP0027 Ophthalmic Prostaglandin Analogs Table of Contents Related Coverage Resources Overview .............................................................. 1 Multi-Source Brand Name Drugs Medical Necessity Criteria ................................... 1 Quantity Limitations Reauthorization Criteria ....................................... 3 Authorization Duration ......................................... 3 Conditions Not Covered....................................... 3 Background .......................................................... 3 References .......................................................... 4 INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. Overview This policy supports medical necessity review for the following ophthalmic prostaglandin analog products: • Lumigan® (bimatoprost 0.01% ophthalmic solution) • Travatan® Z (travoprost 0.004% ophthalmic solution) • Vyzulta™ (latanoprostene bunod 0.024% ophthalmic solution) • Xalatan® (latanoprost 0.005% ophthalmic solution) • Xelpros™ (latanoprost 0.005% ophthalmic emulsion) • Zioptan® (tafluprost 0.0015% ophthalmic solution) Medical Necessity Criteria Ophthalmic prostaglandin analog products (Lumigan, Travatan Z, Vyzulta, Xalatan, Xelpros, Zioptan) are considered medically necessary when the following are met: 1. For the Reduction of Intraocular Pressure (IOP) in Individuals with Open Angle Glaucoma or Ocular Hypertension. Page 1 of 5 Coverage Policy Number: IP0027 Note: Open angle glaucoma includes normal-tension glaucoma, which is also referred to as low-tension glaucoma or normal-pressure glaucoma. Coverage for ophthalmic prostaglandin analog products (Lumigan, Travatan Z, Vyzulta, Xalatan, Xelpros, Zioptan) varies across plans and may require the use of preferred products in addition to the medical necessity criteria listed above. Refer to the customer’s benefit plan document for coverage details. When coverage requires the use of preferred products, there is documentation of ONE of the following: A. The individual has had inadequate efficacy to the number of covered alternatives according to the table below OR B. The individual has a contraindication according to FDA label, significant intolerance, or is not a candidate* for the covered alternatives according to the table below *Note: Not a candidate due to being subject to a warning per the prescribing information (labeling), having a disease characteristic, individual clinical factor[s], other attributes/conditions, or is unable to administer and requires this dosage formulation) Employer Group Non-Covered Products and Preferred Covered Alternatives by Drug List: Non-Covered Standard / Value / Cigna Total Legacy Product Performance Advantage Savings Lumigan TWO of the following: (bimatoprost 0.01% • bimatoprost 0.03 % ophthalmic solution ophthalmic solution) • latanoprost 0.005% ophthalmic solution • travoprost 0.004% ophthalmic solution Contains benzalkonium chloride as preservative Travatan Z EITHER of the following: (travoprost 0.004% • Individual without benzalkonium chloride sensitivity: ± ophthalmic solution) o travoprost 0.004% ophthalmic solution AND Contains sofZia™ o ONE of the following: ionic buffering system . bimatoprost 0.03% ophthalmic solution as preservative (no . latanoprost 0.005% ophthalmic solution benzalkonium • Individual with benzalkonium chloride sensitivity: chloride) ± o travoprost 0.004% ophthalmic solution Vyzulta TWO of the following: (latanoprostene • bimatoprost 0.03 % ophthalmic solution bunod) 0.024% • latanoprost 0.005% ophthalmic solution • travoprost 0.004% ophthalmic solution Contains benzalkonium chloride as preservative Xalatan BOTH of the following: (latanoprost • latanoprost 0.005% ophthalmic solution± 0.005% ophthalmic AND solution) • ONE of the following: o bimatoprost 0.03 % ophthalmic solution Contains travoprost 0.004% ophthalmic solution benzalkonium o Page 2 of 5 Coverage Policy Number: IP0027 Non-Covered Standard / Value / Cigna Total Legacy Product Performance Advantage Savings chloride as preservative Xelpros EITHER of the following: (latanoprost • Individual without benzalkonium chloride sensitivity, TWO of the following: 0.005% ophthalmic o bimatoprost 0.03 % ophthalmic solution emulsion) o latanoprost 0.005% ophthalmic solution o travoprost 0.004% ophthalmic solution Contains potassium • Individual with benzalkonium chloride sensitivity: sorbate 0.47% as travoprost 0.004% ophthalmic solution preservative (no o benzalkonium chloride) Zioptan (tafluprost ANY of the following: 0.0015% • Individual without benzalkonium chloride sensitivity, TWO of the following: ophthalmic solution) o bimatoprost 0.03 % ophthalmic solution o latanoprost 0.005% ophthalmic solution Preservative-free o travoprost 0.004% ophthalmic solution • Individual with benzalkonium chloride sensitivity: o travoprost 0.004% ophthalmic solution • Individual who has sensitivity to other ophthalmic preservatives (for example, potassium sorbate or ionic buffering systems like sofZia™) ±Documentation that individual has tried the bioequivalent generic product AND cannot take due to a formulation difference in the inactive ingredient(s) [for example, difference in dyes, fillers, preservatives] between the brand and the bioequivalent generic product which, per the prescribing physician, would result in a significant allergy or serious adverse reaction When coverage is available and medically necessary, the dosage, frequency, duration of therapy, and site of care should be reasonable, clinically appropriate, and supported by evidence-based literature and adjusted based upon severity, alternative available treatments, and previous response to therapy. Note: Receipt of sample product does not satisfy any criteria requirements for coverage. Reauthorization Criteria Ophthalmic prostaglandin products are considered medically necessary for continued use when initial criteria are met AND there is documentation of beneficial response. Authorization Duration Initial approval duration is up to 12 months. Reauthorization approval duration is up to 12 months. Conditions Not Covered Ophthalmic prostaglandin products are considered not medically necessary for ANY other use including the following (this list may not be all inclusive): 1. Cosmetic Conditions (for example, eyelash growth) Background OVERVIEW Single-entity ophthalmic prostanoids include prostaglandin analogs (Travatan Z, Vyzulta, Zioptan, and latanoprost [Xalatan/generics, Xelpros]) and prostamides (Lumigan, bimatoprost 0.03% [generic to discontinued Page 3 of 5 Coverage Policy Number: IP0027 Lumigan 0.03%])). Rocklatan is a combination product containing netarsudil and latanoprost. All of these are indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma (OAG) or ocular hypertension (OH).1-8 Bimatoprost is also available as a 0.03% ophthalmic solution (marketed as Latisse®) indicated to treat hypotrichosis of the eyelashes by increasing their growth including length, thickness, and darkness.9 Efficacy/Guidelines All of the prostaglandin analogs have demonstrated similar efficacy in lowering IOP.10-13 A recent systematic review and network meta-analysis evaluated 114 randomized controlled studies involving various ophthalmic products for the treatment of primary open angle glaucoma.14 The authors concluded that the prostaglandins (bimatoprost, latanoprost, travoprost, and tafluprost) were more efficacious than drugs in other classes and the within-class differences were generally small. The American Academy of
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