Travoprost Intracameral Implant (iDose TR®)
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
POLICY
The requested drug will be covered with prior authorization when the following criteria are met:
· The requested medication is being used for the reduction of intraocular pressure (IOP) in a patient who has a diagnosis of Open-Angle Glaucoma (OAG) or Ocular Hypertension (OHT)
AND
· The patient does NOT have any of the following:
o Ocular or periocular infection
o Corneal endothelial dystrophy
o Prior corneal transplantation
o Hypersensitivity to Travoprost
LENGTH OF AUTHORIZATION
Approval may be provided for 12 months. Administration may also be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines.
APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS
BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.
ADDITIONAL INFORMATION
For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).
REFERENCES
1. iDose TR - travoprost intracameral implant [package insert]. San Clemente, CA: Glaukos Corp., 2023. Accessed March 2024.
2. iDoseTR. In: Clinical Pharmacology. Tampa (FL): Elsevier. Revised Jan. 2024. Accessed March 2024.
3. Travoprost. In: UpToDate Lexidrug Online. Waltham, MA: UpToDate, Inc.; March 26, 2024. https://online.lexi.com. Accessed March 27, 2024.
4. Travoprost. In: Micromedex® (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 3/27/2024).Accessed March 27, 2024.
ORIGINAL EFFECTIVE DATE: 5/31/2024
MOST RECENT REVIEW DATE: 5/31/2024
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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