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L.5.01.458
Acuvail 0.45% (ketorolac tromethamine PF)
Ilevro 0.3% (nepafenac)
Nevanac 0.1% (nepafenac)
Prolensa 0.07% (bromfenac sodium)
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.
Several ophthalmic corticosteroids and ophthalmic non-steroidal anti-inflammatory products are FDA-approved for the treatment of ocular pain and/or inflammation. Individuals undergoing ocular surgery may require the short-term use of anti-inflammatory ophthalmic products to prevent complications and assist in proper healing. Both generic and branded products are currently available.
Prior authorization is required.
The use of samples by an individual will not be considered current or stable therapy to satisfy Medical Policy requirements.
Nevanac 0.1% (nepafenac ophthalmic suspension) may be considered medically necessary when ALL of the following criteria are met:
The individual is 10 years of age or older and the request is for Nevanac (nepafenac);
The individual has had, or is about to have, cataract extraction; AND
ONE of the following:
The individual has failed (see definition of Medication Failure in Policy Guidelines section) TWO of the following:
diclofenac eye drops;
flurbiprofen eye drops; OR
ketorolac eye drops; OR
The individual has a documented intolerance, contraindication, or hypersensitivity to diclofenac, flurbiprofen, AND ketorolac.
Length of Approval: 2 weeks
Acuvail 0.45% (ketorolac tromethamine PF), Ilevro 0.3% (nepafenac), and Prolensa 0.07% (bromfenac) are considered not medically necessary as there are other formulary alternatives covered by the Plan.
State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
appropriate with regard to standards of good medical practice; and
not solely for the convenience of the Member, his or her Provider; and
the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of medical necessity, “standards of good 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. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary
BCBSMS may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.
Medication FailureMedication failure is defined as disease progression at generally accepted doses as appropriate for the disease state being treated. Dosages below the recommended dose for the specific condition being treated and/or experience of common side effects of medication will not be considered medication failure or lack of response for the purpose of this review.
BCBSMS determines individual medication trial and adherence by a review of pharmacy claims data over the preceding twelve months. Additional information may be requested on a case-by-case basis to allow for proper review. If individual is new to BCBSMS and pharmacy records are needed to confirm medication trials and adherence, it is the responsibility of the individual and/or requesting provider to obtain said records and to submit them to BCBSMS upon request. Medical records from the provider that list previously prescribed medications will not be sufficient to show medication trials or adherence.
01/01/2014: New policy added.
08/03/2015: Code Reference section updated for ICD-10.
05/31/2016: Policy number L.5.01.458 added. Investigative definition updated in Policy Guidelines section.
08/09/2016: Approved by Pharmacy & Therapeutics (P&T) Committee.
08/15/2017: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee.
11/01/2018: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Added drug names to the top of the policy. Policy section updated to add that prior authorization is required. The use of samples by a Member will not be considered current or stable therapy for purposes of Medical Policy review. First policy statement updated to remove Pataday from list of drugs.
08/04/2020: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Added Prolensa 0.07% (bromfenac sodium) to the top of the policy. Emadine (emedastine difumarate) removed from policy. Policy statements updated to include generic drug names and to reference the Policy Guidelines for definition of failure. Policy Guidelines updated to define medication failure. Sources updated.
09/28/2021: Policy title changed from "Ophthalmic Allergy/Anti-Inflammatory Medications" to "Ophthalmic Anti-Inflammatory Medications." Policy description and policy statement extensively re-written to state that Bromday (bromfenac sodium 0.9% ophth drops) or Nevanac (nepafenac 0.1% ophth drops) are considered medically necessary if certain criteria are met. Removed coverage for the following products: Alocril 2% (nedocromil sodium), Alomide 0.1% (lodoxamide tromethamine), Bepreve 1.5% (bepotastine besilate), and Lastacaft 0.25% (alcaftadine). Policy guidelines updated to add the definition of medically necessary and medication failure. Sources section updated.
11/03/2022: Policy updated to remove coverage for "Bromday (bromfenac sodium 0.9% ophth drops)." Sources updated.
02/01/2023: Policy Exceptions updated to add the following: State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.
10/01/2024: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy language updated to change "patients" to "individuals." Sources updated.
09/09/2025: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy description and policy section revised with minor changes for clarity purposes; coverage criteria unchanged. Sources updated.
Acuvail prescribing information. Allergan, Inc. May 2024. Last accessed July
2025.
Ilevro prescribing information.
Harrow Eye, LLC. February 2024.
Last accessed July
2025
.
Nevanac prescribing information.
Harrow Eye, LLC. February 2024.
Last accessed July
2025
.
Prolensa prescribing information. Bausch & Lomb Incorporated. June 2025. Last accessed July
2025
.
None