Pharmacy Prior Authorization Criteria

Ophthalmic NSAIDs

Indications for Prior Authorization

BROMSITE (bromfenac)

• For diagnosis of Postoperative Inflammation and Prevention of Ocular Pain
  Indicated for the treatment of postoperative inflammation and prevention of ocular pain in patients undergoing cataract surgery.

ILEVRO (nepafenac)

• For diagnosis of Postoperative inflammation
  Indicated for the treatment of pain and inflammation associated with cataract surgery.

NEVANAC (nepafenac)

• For diagnosis of Postoperative inflammation
  Indicated for the treatment of pain and inflammation associated with cataract surgery.

Prolensa (bromfenac ophthalmic solution)

• For diagnosis of Postoperative inflammation
  Indicated for the treatment of postoperative inflammation and reduction of ocular pain in patients who have undergone cataract surgery.

Criteria

Ilevro, Nevanac

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• One of the following:
• Patient is greater than 10 but less than 18 years of age [A]
OR
• Trial and failure (of a minimum 30-day supply), contraindication, or intolerance to one of the following generics:
• Diclofenac ophthalmic solution
• Flurbiprofen ophthalmic solution
• Ketorolac ophthalmic solution

Brand Bromsite, Brand Prolensa, Generic bromfenac ophthalmic solution 0.075%, Generic bromfenac ophthalmic solution 0.07%

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (of a minimum 30-day supply), contraindication, or intolerance to one of the following generics:
• Diclofenac ophthalmic solution
• Flurbiprofen ophthalmic solution
• Ketorolac ophthalmic solution

P & T Revisions

2024-10-30, 2024-09-02, 2024-03-27, 2024-03-06, 2023-11-01, 2022-10-06, 2021-09-22, 2021-05-21, 2020-09-09, 2019-10-02

References

1. Bromsite Prescribing Information. Sun Pharmaceutical Industries, Inc.; Cranbury, NJ. April 2023.
2. Ilevro Prescribing Information. Novartis Pharmaceuticals Corporation, East Hanover, New Jersey 07936. April 2023.
3. Nevanac Prescribing Information. Novartis Pharmaceuticals Corporation, East Hanover, New Jersey 07936. April 2023.
4. Bromfenac Opthalmic Solution 0.075% Prescribing Information. Sun Pharmaceutical Industries, Inc.; Cranbury, NJ. February 2024.

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End Notes

1. Pediatric patients age greater than 10 but less than 18 years of age are allowed to bypass the trial and failure requirement because Ilevro and Nevanac are approved for this pediatric population, but not Bromsite. The safety and efficacy in pediatric patients below the age of 18 years have not been established for Bromsite. [1, 2, 3]

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Revision History

• 2024-10-30: update guideline
• 2024-09-02: 2024 Annual Review. Updated references. Background updates.
• 2024-03-27: update guideline
• 2024-03-06: Added generic bromfenac as target to guideline.
• 2023-11-01: Annual Review, no changes.
• 2022-10-06: 2022 UM Annual Review.
• 2021-09-22: 2021 UM Annual Review.
• 2021-05-21: Addition of EHB formulary to guideline, no changes to criteria
• 2020-09-09: 2020 UM Annual Review.
• 2019-10-02: 2019 Annual Review. SL 10.02.19

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