generic bepotastine besilate 1.5% ophthalmic solution — Medical Mutual

allergic conjunctivitis

Preferred products

If the patient has tried one Step 1 product, authorization for a Step 2 product may be given.
If the patient requires the concurrent use of generic loteprednol etabonate 0.2% ophthalmic suspension and an H1 antagonist or an H1 antagonist/mast cell stabilizer, approve generic loteprednol etabonate 0.2% ophthalmic suspension.
If the patient has tried a different ophthalmic steroid for the current condition, approve generic loteprednol etabonate 0.2% ophthalmic suspension.
Step Therapy Exception Criteria: Approve for 1 year if the patient meets A, B, or C: A. The patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents [documentation required]; OR B. The patient has a contraindication to all preferred agents [documentation required]; OR C. The patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND meets one of the following: 1. The patient has at least 130 days of prescription claims history on file showing ≥90 days of the requested non-preferred agent, and there is no generic equivalent available; OR 2. If 130-day history is unavailable, prescriber must verify ≥90 days of requested non-preferred agent via paid claims (not samples/coupons) AND there is no generic equivalent available.

For continuation of therapy, all approvals are provided for 1 year unless otherwise noted.

1 year