Appeal type: Formulary Exception
Decision: Overturned


Diagnosis: Glaucoma

Treatment: Lumigan (Bimatoprost)

The insurer denied coverage for Lumigan (Bimatoprost)

The denial is overturned
 

The patient is an adult with primary open angle glaucoma.

In a letter, the request for Lumigan (bimatoprost) was denied because it stated that the patient has not tried and had an inadequate treatment response or intolerance to the required number of formulary alternatives, or, have a documented clinical reason such as expected adverse reaction or contraindication that prevents patient from trying formulary alternatives (Latanoprost and Travoprost).

In the appeal, the provider noted that the patient has tried both Latanoprost and Travoprost but experienced sensitivity and allergies. The patient has been on Lumigan since 2016 and needs to stay on Lumigan for intraocular pressure control.

The formulary drug(s) would likely cause the patient an adverse reaction. The patient has a documented adverse reaction to the formulary alternatives, Latanoprost and Travoprost. In the appeal, the provider documents that the patient has tried and has sensitivity and allergies to both Latanoprost and Travoprost.      

The formulary drug(s) has not been ineffective based on the patient's clinical history. There is no documentation that the formulary drugs have been ineffective in the documentation provided.     

The requested drug would be more effective than the formulary drug. It was documented that the patient had allergic reactions to the formulary drugs, but not to Lumigan. Lumigan has been used in this patient and been effective. Therefore, the request for Lumigan is medically necessary.

Huang, A. S., & Meyer, J. J. (2022), "Bimatoprost ophthalmic solution is an eye drop medication used to lower intraocular pressure in patients with open-angle glaucoma and ocular hypertension and cosmetically to treat hypotrichosis. It is a prostaglandin F2 alpha analog."

Subbulakshmi S, Kavitha S, Venkatesh R. (2023), "Bimatoprost was approved by the Food and Drug Administration (FDA) in the year 2001. Bimatoprost is a fatty acid with an ethyl amide, rather than an isopropyl ester, at the C-1 carbon of the -chain. It has a dual action mechanism, which involves an increase of uveoscleral outflow and also acting on the prostamide receptors present in the trabecular meshwork, thus increasing the conventional outflow. It is the most efficient drug in reducing intraocular pressure (IOP) because of its dual action but has more adverse drug reactions. It is available in two strengths, 0.03% and 0.01%, and has a once-daily dosage. It can be stored at temperatures between 15C and 25C."

Klimko, P. G., & Sharif, N. A. (2019), "Topical ophthalmic formulations of analogues of the endogenous arachidonic acid cyclooxygenase metabolite are the standard of care treatment for the blinding disease glaucoma. These are the most potent and efficacious medical therapies for lowering intraocular pressure (IOP), the most important risk factor identified for disease progression. They have few side effects and offer the convenience of once-a-day dosing. Carefully designed experiments demonstrated that esterification of the carboxylic acid afforded potent and efficacious topical ocular hypotensive activity."

The carrier's denial of a request for a Formulary Exception for Lumigan (bimatoprost) to treat glaucoma is overturned.