UPNEEQ (oxymetazoline hydrochloride)

UPNEEQ (oxymetazoline hydrochloride) 

SELF ADMINISTRATION - OPHTHALMIC SOLUTION

Indication for Prior Authorization:

Indicated for the treatment of acquired blepharoptosis in adults

Coverage Criteria:

• Patient is 18 years of age and older, AND
• Prescribed by or in consultation with an ophthalmologist or optometrist, AND
• Diagnosis of acquired blepharoptosis, AND
• Patient has obstructed visual field in primary gaze or downgaze due to blepharoptosis, AND
• Other treatable causes of blepharoptosis have been ruled out (e.g., recent botulinum toxin injection, myasthenia gravis), AND
• One of the following:
  • Marginal reflex distance-1 (MRD-1) is ≤ 2 mm in primary gaze, OR
  • Marginal reflex distance-1 (MRD-1) is ≤ 2 mm in downgaze, OR
  • Superior visual field loss of at least 12 degrees or 24 percent

Reauthorization Criteria:

• Documentation of a positive clinical response to therapy (e.g., improvement in the superior visual field, increase in Marginal reflex distance-1 [MRD-1]), AND
• One of the following:
  • Marginal reflex distance-1 (MRD-1) is ≤ 2 mm in primary gaze, OR
  • Marginal reflex distance-1 (MRD-1) is ≤ 2 mm in downgaze, OR
  • Superior visual field loss of at least 12 degrees or 24 percent

Dosing:

• Instill 1 drop in affected eye(s) once daily

Coverage Duration:

• Initial: 6 weeks
• Reauthorization: 6 weeks

Authorization is Not Covered for the Following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics Committee.

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

Review History:

• 10/1/2020- Original review

References:

• Upneeq [package insert]. Bridgewater, NJ. RVL Pharmaceuticals, Inc. August 2020.
• 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 August 31, 2020.
• 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 10, 2020.
• 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 10, 2020.