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Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
DESCRIPTIONGlaucoma is a disease of the optic nerve with characteristic changes in the optic disc and defects in the visual field with or without raised intraocular pressure (IOP). Chronic open angle glaucoma (COAG) is defined as glaucoma without evident secondary cause, which follows a chronic time course and occurs in the presence of an open anterior chamber angle. Ocular hypertension (OHT) occurs when consistently or recurrently elevated IOP (> 21 mm Hg) exists in the absence of clinical evidence of optic nerve damage or visual field defect.
Prostaglandin analogues have been shown to lower IOP more than beta blockers. The topical prostaglandin analogues are recommended as first line therapy for glaucoma by the National Institute for Health and Clinical Excellence guidelines, the Canadian Ophthalmological Society guidelines, as well as the American Academy of Ophthalmology Preferred Practice Pattern guidelines.
All agents in the prostaglandin analog class can cause permanent changes to ocular tissues by increasing pigmentation of the iris and eyelid and growth of eyelashes. A clinical trial that studied safety and efficacy of prostaglandin analogues found iris pigmentation changes occurred within 24 months in 94% of patients. The rate of progression of pigmentation change decreased over time.
According to The AAO 2010 guidelines for treatment of open angle glaucoma, the prostaglandin analogs lower intraocular pressure (IOP) the most of all other agents used for the treatment of glaucoma. Prostaglandin analogs lower IOP by 25%-33%; beta blockers lower IOP by 20-25%; alpha adrenergic agonists lower IOP by 20-25%; parasympathomimetic agents lower IOP by 20-25%; and carbonic anhydrase inhibitors lower IOP by 15%-20%.
The dosage of ophthalmic prostaglandins should not exceed once daily. More frequent administration may decrease the intraocular pressure lowering effects of the medication.
POLICYTravatan Z will be approved when ONE of the following is met:
POLICY EXCEPTIONSTravatan Z prior authorization is not required for Federal Employee Program (FEP) and State Health Plan members.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
01/01/2014: New policy added.
07/23/2015: Code Reference section updated for ICD-10.
05/31/2016: Policy number added. Investigative definition updated in the Policy Guidelines section.
SOURCE(S)1. Lumigan prescribing information. Allergan, Inc. March 2012.
2. Travatan Z prescribing information. Alcon Laboratories, Inc. September 2011.
3. Xalatan prescribing information. Pfizer Inc/Pharmacia & Upjohn Company. August 2012.
4. Zioptan prescribing information. Merck & Co., Inc. August 2013.
5. National Institute for Health and Clinical Excellence (NICE). Glaucoma: diagnosis and management of chronic open angle glaucoma. NICE clinical guideline 85. April 2009 Available at: http://www.nice.org.uk/nicemedia/live/12145/43839/43839.pdf. Accessed October 20, 2010.
6. Canadian Ophthalmological Society. Evidence-based guidelines for the management of glaucoma in the adult eye. June 2009. Available at: http://www.supereyecare.com/residents/GlaucomaCOSGuidelines.pdf. Accessed October 20, 2010.
7. American Academy of Ophthalmology. Primary Open-Angle Glaucoma. Preferred Practice Pattern. San Francisco, CA: American Academy of Ophthalmology; 2010. Available at: http://one.aao.org/asset.axd?id=56c908e3-a939-45ea-b12b-8fe609f547b0. Accessed August 8, 2012.
8. Vass C, Hirn C, Sycha T, Findl O, Bauer P, Schmetterer L. Medical interventions for primary open angle glaucoma and ocular hypertension. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003167.
9. Servat JJ and Bernardino CR. Effects of Common Topical Antiglaucoma Medications on the Ocular Surface, Eyelids and Periorbital Tissue. Drugs Aging. 2011 Apr 1;28(4):267-82.
10. Faridi UA, Saleh TA, Ewings P, et al. Comparative study of three prostaglandin analogues in the treatment of newly diagnosed cases of ocular hypertension, open-angle and normal tension glaucoma. Clin Experiment Ophthalmol. 2010 Oct;38(7):678-82.
11. Rescula prescribing information. Sucampo Pharma Americas LLC. January 2013.
12. Travoprost prescribing information. Par Pharmaceutical, Inc. April 2013.
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.