Pharmacy Prior Authorization Criteria

Ophthalmic Prostaglandins

Indications for Prior Authorization

Xelpros (latanoprost)

• For diagnosis of Open-angle glaucoma
  Indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma.

• For diagnosis of Ocular hypertension
  Indicated for the reduction of elevated intraocular pressure (IOP) in patients with ocular hypertension.

Vyzulta (latanoprostene bunod)

• For diagnosis of Open-angle glaucoma
  Indicated for the reduction of intraocular pressure in patients with open-angle glaucoma.

• For diagnosis of Ocular hypertension
  Indicated for the reduction of intraocular pressure in patients with ocular hypertension.

Iyuzeh (latanoprost ophthalmic solution)

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

Criteria

Iyuzeh, Xelpros, Vyzulta

Step Therapy

Length of Approval: 12 Month(s)

• 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
• Generic travoprost

P & T Revisions

2025-01-08, 2024-01-05, 2023-11-02, 2023-01-20, 2022-01-27, 2021-01-19, 2020-09-30, 2020-03-02

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.

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Revision History

• 2025-01-08: 2025 Annual Review.
• 2024-01-05: 2024 Annual Review.
• 2023-11-02: Added Iyuzeh as target to guideline.
• 2023-01-20: 2023 Annual Review
• 2022-01-27: Annual Review
• 2021-01-19: Annual Review: updated minimum trial and failure duration verbiage
• 2020-09-30: Program Update: added lookback period and removed Brand Travatan Z as an option on the ST program
• 2020-03-02: Add travoprost in ST

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