Upneeq (oxymetazoline) 0.1% ophthalmic solution — United Healthcare

Initial criteria

• Diagnosis of acquired blepharoptosis
• Functional impairment related to the position of the eyelid
• ONE of the following: Marginal reflex distance-1 (MRD-1) ≤ 2 mm in primary gaze OR MRD-1 ≤ 2 mm in down gaze OR superior visual field loss ≥ 12 degrees or ≥ 24 percent
• Other treatable causes of blepharoptosis have been ruled out (e.g., recent botulinum toxin injections, myasthenia gravis)
• Prescribed by or in consultation with an optometrist OR ophthalmologist

Reauthorization criteria

• Documentation of positive clinical response to therapy

Approval duration

12 months