Iodipine 1% — Medical Mutual
glaucoma
Preferred products
- Generic brimonidine tartrate 0.1% ophthalmic solution
- Generic brimonidine tartrate 0.15% ophthalmic solution
- Generic brimonidine tartrate 0.2% ophthalmic solution
- Generic apraclonidine 0.5% ophthalmic solution
Initial criteria
- Patient has tried a preferred medication; OR
- Patient is undergoing argon laser trabeculoplasty, argon laser iridotomy, or Nd:YAG posterior capsulotomy; OR
- Patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents [documentation required]; OR
- Patient has a contraindication to all preferred agents [documentation required]; OR
- Patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days [verification required] AND meets ONE of the following:
- - Patient has at least 130 days of prescription claims history on file AND claims history supports receipt of the requested non-preferred agent for 90 days within a 130-day look-back period AND there is no generic equivalent available for the requested non-preferred product; OR
- - When 130 days of prescription claims history is unavailable, prescriber verifies that the patient has been receiving the requested non-preferred agent for 90 days AND patient has been receiving the non-preferred agent via paid claims (not samples/coupons/waivers) AND there is no generic equivalent available for the requested non-preferred product
Reauthorization criteria
- Continuation of therapy with the requested non-preferred agent is approved for 1 year unless otherwise noted
Approval duration
1 year