Payer PolicyActive
iDose®TR (travoprost intracameral implant)
EVICORE-MEDICAL_DRUG-ACC674F4
EviCore by Evernorth
Effective: July 1, 2025
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Covered for adults (≥18) with open‑angle glaucoma or ocular hypertension to reduce IOP — one iDose TR implant per treated eye (maximum two implants per patient), one‑time intracameral use only, and not for retreatment of eyes previously treated with iDose TR. Key requirements: documented inadequate efficacy or severe adverse events to at least two ophthalmic prostaglandins and to at least two ophthalmic agents from two different pharmacologic classes, and administration by or under the supervision of an ophthalmologist.
Coverage Criteria Preview
Key requirements from the full policy
"iDose TR is indicated for the reduction of intraocular pressure (IOP) in patients with open-angle glaucoma (OAG) or ocular hypertension (OHT)."
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