Latanoprostene bunod (Vyzulta®)

SELF ADMINISTRATION

Indications for Prior Authorization:

  • Indicated for the reduction of intraocular pressure in patients with open-angle glaucoma or ocular hypertension

Patients must meet the following criteria for the indication(s) above:

  • Patients are 17 years of age or older, AND
  • Diagnosis of open-angle glaucoma or ocular hypertension, AND
  • Tried and failed generic Latanoprost, AND
  • Tried and failed one of the following:
    • Ophthalmic beta blocker (e.g. Timolol), OR
    • Ophthalmic alpha-2 adrenergic agnoist (e.g. Brimonidine), AND
  • Does not exceed 5 mL per 30 days

Dosing:

  • One drop in the affected eye(s) once daily in the evening

Approval:

  • 1 year

Last review date: June 26, 2019