Pharmacy Prior Authorization Criteria

Upneeq (oxymetazoline hydrochloride)

For diagnosis of Blepharoptosis
Indicated for the treatment of acquired blepharoptosis in adults.

Excluded Use

For diagnosis of Cosmetic Purposes

Requests for coverage of Upneeq when used solely for lifting the eyelid to improve appearance is not authorized and will not be approved. This use is considered cosmetic only.

Prior Authorization (Initial Authorization)

Length of Approval: 6 Week(s) [1, 4]
For diagnosis of Blepharoptosis

Diagnosis of acquired blepharoptosis
Patient has obstructed visual field in primary gaze or down gaze due to blepharoptosis

AND

Marginal reflex distance-1 (MRD-1) is less than or equal to 2 mm in primary gaze
Marginal reflex distance-1 (MRD-1) is less than or equal to 2 mm in down gaze
Superior visual field loss of at least 12 degrees or 24 percent

AND

Other treatable causes of blepharoptosis have been ruled out (e.g., recent botulinum toxin injection, myasthenia gravis)

AND

Prior Authorization (Reauthorization)

Length of Approval: 6 Week(s) [1, 4]
For diagnosis of Blepharoptosis

Patient demonstrates positive clinical response to therapy (e.g., improvement in superior visual field, increase in Marginal reflex distance-1 [MRD-1])

AND

Marginal reflex distance-1 (MRD-1) is less than or equal to 2 mm in primary gaze
Marginal reflex distance-1 (MRD-1) is less than or equal to 2 mm in down gaze
Superior visual field loss of at least 12 degrees or 24 percent

2024-09-30, 2023-10-30, 2023-09-22, 2022-09-26, 2021-09-07, 2021-09-08

Upneeq [package insert]. Bridgewater, NJ. RVL Pharmaceuticals, Inc. May 2023.
Cahill K, Bradley E, Meyer D et al. Functional Indications for Upper Eyelid Ptosis and Blepharoplasty Surgery. Ophthalmology. 2011;118(12):2510-2517.
Alsuhaibani A, Burkat C, Plemel D et al. Blepharoptosis - EyeWiki. Eyewiki.aao.org. https://eyewiki.aao.org/Blepharoptosis. Published 2020. Accessed September 2, 2021.
RVL Pharmaceuticals, Inc. Study of the Safety and Efficacy of RVL-1201 in the Treatment of Acquired Blepharoptosis. Available from: https://clinicaltrials.gov/ct2/show/NCT02436759. NCT02436759. Accessed September 2, 2021.
RVL Pharmaceuticals, Inc. Study of Safety and Efficacy of RVL-1201 in the Treatment of Blepharoptosis. Available from: https://clinicaltrials.gov/ct2/show/NCT03565887. NCT03565887. Accessed September 2, 2021.