Istalol (brand and generic) — Medical Mutual

Preferred products

• generic betaxolol 0.5% ophthalmic solution
• generic carteolol 1% ophthalmic solution
• generic levobunolol 0.5% ophthalmic solution
• generic timolol maleate 0.25% and 0.5% ophthalmic solution (generic to Timoptic)

Initial criteria

• Patient has tried one preferred product; OR
• Patient has a known benzalkonium chloride or benzododecinium bromite sensitivity AND a known sensitivity to other ophthalmic preservatives AND cannot use timolol maleate 0.5% ophthalmic solution (generic to Timoptic in Ocudose); approve Timoptic in Ocudose 0.25%; OR
• Step Therapy Exception Criteria:
• A. Patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred products [documentation required]; OR
• B. Patient has a contraindication to all preferred products [documentation required]; OR
• C. Patient is continuing therapy with the requested non-preferred product after being stable for at least 90 days AND meets ONE of the following:
• 1. Patient has at least 130 days of prescription claims history on file and claims history supports receipt of the requested non-preferred product for 90 days within a 130-day look-back period AND there is no generic equivalent available; OR
• 2. When 130 days of prescription claims history file is unavailable, prescriber must verify that patient has been receiving the requested non-preferred product for 90 days via paid claims (not samples or coupons) AND there is no generic equivalent available

Reauthorization criteria

• Continuation of therapy approved for 1 year unless noted otherwise

Approval duration

1 year