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

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.