ROCKLATAN (netarsudil and latanoprost)

SELF ADMINISTRATION

Indications for Prior Authorization:
  • Indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension
Patients must meet the following criteria for the indication(s) above:
  • Patient is 18 years of age or older, AND
  • Diagnosis of open-angle glaucoma or ocular hypertension as confirmed by chart note documentation, AND
  • Patient has tried and failed Latanoprost AND one other agent from a different pharmacologic class (e.g. ophthalmic beta-blocker, ophthalmic alpha-2 adrenergic agonist, carbonic anhydrase inhibitors), AND
  • Does not exceed a quantity of 2 bottles (5 mL) per month
Dosing:
  • One drop into the affected eye(s) once daily
Approval:
  • Initial: 1 year
  • Renewal: 1 year if chart notes document a positive response to therapy

Last review date: August 26, 2020

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