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
Indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma. -
For diagnosis of Open-angle glaucoma, Ocular hypertension
Indicated for the reduction of elevated intraocular pressure (IOP) in patients with ocular hypertension.
Omlonti (omidenepag isopropyl ophthalmic solution)
-
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.
Zolymbus (bimatoprost ophthalmic gel)
-
For diagnosis of Open-angle glaucoma
Indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. -
For diagnosis of 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: When approved; no reauthorization required
- 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
- Generic bimatoprost
Omlonti, Zolymbus
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
- Generic bimatoprost
P & T Revisions
2026-06-23, 2026-05-29, 2026-04-01, 2025-12-23, 2025-12-18, 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
- Xelpros Prescribing Information. Sun Pharmaceutical Industries, Inc. Cranbury, NJ. February 2021.
- Vyzulta Prescribing Information. Bausch & Lomb Incorporated. Bridgewater, NJ. May 2019.
- Iyuzeh Prescribing Information. Thea Pharma Inc. Waltham, MA. December 2022.
- Omlonti Prescribing Information. Santen Inc. Emeryville, CA. Sept 2022.
- Zolymbus Prescribing Information.Thea Pharma Inc. Waltham, MA . Sept 2025.
Revision History
- 2026-06-23: update guideline
- 2026-05-29: update guideline
- 2026-04-01: update guideline
- 2025-12-23: 2026 Annual Review
- 2025-12-18: no criteria changes, added IL statute operational note
- 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
HEALTHY LIVING