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Effective Date: 01/01/2021 Title: Upneeq (oxymetazoline)
Revision Date: Document: BI680:00
CPT Code(s):
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Upneeq (oxymetazoline) requires prior authorization.

2)    Upneeq is used to treat acquired blepharoptosis in adults.

3)    Upneeq is covered under the pharmacy benefit.


Medical Statement

Upneeq is considered medically necessary for members meeting the following criteria:

 

1)    Diagnosis of acquired blepharoptosis/ptosis (e.g., aponeurotic, neurologic ptosis);

2)    Prescribed by or in consultation with an optometrist or ophthalmologist;

3)    Age > 13 years;

4)    Member does not have congenital or mechanical ptosis;

5)    Documentation of baseline marginal reflex distance 1 (MRD-1) < 2mm;

6)    Dose does not exceed 1 carton (30 single use containers) per affected eye per month.

Approval Duration: 12 months

 

Reauthorization for 12 months is approved if member is responding positively to therapy as evidenced by, but not limited to, improvement in visual peripheral field test (e.g., LPFT) or MRD-1.


Reference
Upneeq Prescribing Information. Bridgewater, NJ: RVL Pharmaceuticals, Inc.; July 2020.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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