Ophthalmic Prostaglandins [IYUZEH (latanoprost), VYZULTA (latanoprostene bunod), XELPROS (latanoprost)]

Self-Administration – ophthalmic solution

Diagnosis considered for coverage: 

 

Iyuzeh (latanoprost ophthalmic solution 0.005%)

  • Open-angle glaucoma, Ocular hypertension: Indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension.

Vyzulta (latanoprostene bunod solution 0.024%)

  • Open-angle glaucoma: Indicated for the reduction of intraocular pressure in patients with open-angle glaucoma. 
  • Ocular hypertension: Indicated for the reduction of intraocular pressure in patients with ocular hypertension.

Xelpros (latanoprost ophthalmic emulsion 0.005%)

  • Open-angle glaucoma: Indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma. 
  • Ocular hypertension: Indicated for the reduction of elevated intraocular pressure (IOP) in patients with ocular hypertension.
Coverage Criteria:

 

For diagnosis of open-angle glaucoma or ocular hypertension:

  • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication; AND
  • Trial and failure (of a minimum 25 days supply), contraindication, or intolerance to ALL of the following: 
    • Generic latanoprost 
    • Lumigan (bimatoprost)
    • Generic travoprost 

 

Dosing:
  • The recommended dosage is one drop in the affected eye(s) once daily in the evening.
  • If more than one topical ophthalmic drug is being used, the drugs should be administered at least five minutes apart. 
  • Contact lenses should be removed prior to the administration and may be reinserted 15 minutes after administration.
Coverage Duration:
  • 1 year
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 (P&T) Committee.
Additional Information: 
  • Benzalkonium chloride (BAK) is a detergent and frequently used preservative in most classes of ophthalmic solutions; BAK can cause ocular toxicity and subsequent tolerability issues in some patients.
  • Iyuzeh (latanoprost 0.005% ophthalmic solution) is preservative-free, and the drops are supplied in single-dose containers.
  • Other BAK-free ophthalmic prostaglandin analogs include Travatan Z (travoprost 0.004% solution) preserved with sofZia (boric acid, propylene glycol, sorbitol, zinc chloride), Xelpros (latanoprost 0.005% emulsion) preserved with potassium sorbate, and preservative-free Zioptan (tafluprost 0.0015% solution).
  • Xalatan (latanoprost 0.005% ophthalmic solution) is preserved with BAK 0.02%.
Policy Updates:
  • 06/01/2024 – New policy for Iyuzeh & Xelpros. Updated policy for Vyzulta. Combined ophthalmic prostaglandins into one policy. Approved by WHA P&T Committee. (P&T, 05/21/2024)
  • 07/30/2020 – New policy for Vyzulta approved by P&T
References:
  1. Xelpros Prescribing Information. Sun Pharmaceutical Industries, Inc. Cranbury, NJ. February 2021. 
  2. Vyzulta Prescribing Information. Bausch & Lomb Incorporated. Bridgewater, NJ. May 2019. 
  3. Iyuzeh Prescribing Information. Thea Pharma Inc. Waltham, MA. December 2022.

Last review date: June 1, 2024

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