CurrentCignaPolicy IP0027

Ophthalmic - Glaucoma - Prostaglandins

Cigna coverage policy for prescription ophthalmic prostaglandin products (and select rho kinase combination) for treatment of open-angle glaucoma or ocular hypertension; defines prior authorization, preferred-product trial requirements, and exclusions for cosmetic use.

Policy Summary

PayerCigna

PolicyOphthalmic - Glaucoma - Prostaglandins

Policy CodePolicy IP0027

Change TypeCoverage criteria updates and product-specific trial requirement changes

Effective DateAug 1, 2025

Next Review Date

Key ActionObtain prior authorization — approvals are provided for 1 year when criteria (including required preferred-product trials) are met.

SourceLink

POLICY UPDATE CHANGES

Policy name updated from 'Ophthalmic Glaucoma Agents - Prostaglandin Analogs and Rho Kinase Inhibitors' to 'Ophthalmic - Glaucoma - Prostaglandins.'

Preferred product criteria for Lumigan and Vyzulta updated to require four preferred product trials (was previously two) and added bimatoprost 0.03% and tafluprost 0.0015% in various plan types.

Travatan Z preferred-product requirement changed to require the bioequivalent generic product trial rather than generic plus another preferred product.

Rhopressa criteria for Individual and Family Plans: removed trials of parasympathomimetic, topical/oral carbonic anhydrase inhibitors and a second prostaglandin analog; added trial of an ophthalmic carbonic anhydrase inhibitor and notes with examples.

11listed branded/generic ophthalmic products included

1 yearstandard approval duration for covered indications

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Coverage Criteria

inv-01: FDA-Approved Indications — Ophthalmic Prostaglandins are considered medically necessary when ONE of the following is met (1 or 2)

Ophthalmic Prostaglandins are considered medically necessary when ONE of the following is met (1 or 2):

Covered Indications: 1. Ocular hypertension — Approve for 1 year if Preferred product criteria is met for the products listed in the policy tables; 2. Open-angle glaucoma (includes normal-tension glaucoma) — Approve for 1 year if Preferred product criteria is met for the products listed in the policy tables.Approve for 1 year

Open-angle glaucoma includes normal-tension glaucoma.

inv-02: Product-specific preferred/trial criteria — detailed per-product preferred-product and prior-trial requirements, some varying by plan type

Product-specific preferred product and trial criteria (selected highlights by plan type):

Iyuzeh (latanoprost 0.005%): Employer and Individual/Family Plans: Approve if ONE of the following: (1) patient has tried generic latanoprost 0.005% ophthalmic solution and cannot take the brand due to a formulation difference in inactive ingredients (e.g., dyes, fillers, preservatives) that would, per prescriber, result in a significant allergy or serious adverse reaction; OR (2) prescriber documents significant allergy/sensitivity to benzalkonium chloride (BAK) or other preservatives.

See Employer Plans (chunk 7) and Individual and Family Plans (chunks 10,12) for exact wording.

Lumigan (bimatoprost variants): Employer and Individual/Family Plans: Patient must have tried ALL of the following: (1) latanoprost 0.005% ophthalmic solution [BAK preservative] (Xalatan); (2) bimatoprost 0.03% ophthalmic solution [BAK preservative]; (3) travoprost 0.004% ophthalmic solution [ionic buffering system, no BAK] (Travatan Z); and (4) tafluprost 0.0015% ophthalmic solution [preservative-free] (Zioptan). Note: a trial of the brand version of a generic equivalent product counts toward the requirement.

Employer Plans chunk 7; Individual and Family Plans chunk 10.

Travatan Z (travoprost 0.004%): Employer and Individual/Family Plans: Patient must have tried the bioequivalent generic travoprost 0.004% ophthalmic solution AND cannot take the brand due to a formulation difference in inactive ingredients that would result in a significant allergy or serious adverse reaction, per the prescriber.

Employer Plans chunk 7; Individual and Family Plans chunk 11.

Xalatan / Xelpros (latanoprost formulations): Employer and Individual/Family Plans: For Xalatan (brand latanoprost 0.005%), patient must have tried the bioequivalent generic latanoprost 0.005% and cannot take the brand due to formulation differences in inactive ingredients causing significant allergy/serious adverse reaction. For Xelpros (latanoprost 0.005% emulsion), criteria are ONE of: (1) tried generic latanoprost 0.005% and cannot take due to formulation difference; OR (2) prescriber documents significant allergy/sensitivity to BAK.

See chunks 8,9,12 for plan-specific criteria.

Zioptan (tafluprost 0.0015%): Employer and Individual/Family Plans: Patient must have tried the bioequivalent generic tafluprost 0.0015% ophthalmic solution AND cannot take the brand due to formulation differences in inactive ingredients that would result in a significant allergy or serious adverse reaction, per the prescriber. Zioptan is preservative-free.

Chunks 8,9,12.

Rhopressa and Rocklatan (netarsudil-containing products): Individual and Family Plans: Rhopressa (netarsudil 0.02%) criteria require the patient to have tried ONE ophthalmic prostaglandin analog and additional required prior treatments per the policy; Rocklatan (netarsudil 0.02%/latanoprost 0.005%) requires inability to use the single agents Rhopressa and latanoprost concurrently. See policy for plan distinctions and detailed prior-treatment requirements.

Chunks 10 and 11 contain the revised plan-specific requirements.

Ophthalmic prostaglandin products are not medically necessary when prescribed for any indication other than treatment of ocular hypertension or open‑angle glaucoma (including normal‑tension glaucoma). Requests for these agents for non‑labeled or other uses will be denied as not medically necessary.

Cosmetic uses of ophthalmic prostaglandins are specifically excluded from coverage. An explicit example is treatment to promote eyelash growth (for example, products used for the Latisse indication); such requests will be denied as not medically necessary.

Included Products / Coding

Included ophthalmic products (by name)mixed

Iyuzeh	latanoprost 0.005% ophthalmic solution - Thea
Lumigan	bimatoprost 0.01% ophthalmic solution - AbbVie
Rhopressa	netarsudil 0.02% ophthalmic solution - Alcon Laboratories
Rocklatan	netarsudil 0.02%/latanoprost 0.005% ophthalmic solution - Alcon Laboratories
Travatan Z	travoprost 0.004% ophthalmic solution [benzalkonium chloride-free] - Sandoz, generic
Vyzulta	latanoprostene bunod 0.024% ophthalmic solution - Bausch + Lomb
Xalatan	latanoprost 0.005% ophthalmic solution - Viatris Special, generic
Xelpros	latanoprost 0.005% ophthalmic emulsion - Sun
Zioptan	tafluprost 0.0015% ophthalmic solution - Thea, generic

Provider Actions and Billing

Prior Authorization

Prior Authorization Required

Prior Authorization is required for ophthalmic prostaglandins. Approvals are provided for 1 year when criteria are met.

Prior Authorization required
Approval duration: 1 year when criteria are met

Step Therapy

Preferred Product Trial Requirements

Step-therapy / preferred-product trials are required for branded ophthalmic prostaglandins. Providers must document trials of preferred or generic equivalents and specify reasons (e.g., formulation differences or significant allergy/sensitivity) why the preferred product cannot be used. Brand-to-generic or generic-to-brand trials count when the prescriber documents intolerance to inactive ingredients (e.g., dyes, fillers, preservatives) that would cause a significant allergy or serious adverse reaction.

Preferred product or bioequivalent generic must be tried first when specified for individual products
If patient cannot use preferred product due to formulation differences in inactive ingredients (per prescriber), that supports coverage of the requested product

Background

Ophthalmic prostaglandin analogs reduce elevated intraocular pressure (IOP) and are indicated for lowering IOP in patients with open‑angle glaucoma or ocular hypertension. Lowering IOP with these agents reduces the risk of disease progression; open‑angle glaucoma includes normal‑tension glaucoma for treatment considerations. These agents are covered only for those ophthalmic indications when prior authorization and any product‑specific trial requirements are met.

Definitions

Normal-tension glaucoma — definition and note

DefinitionNormal-tension glaucoma: a form of open-angle glaucoma with presenting intraocular pressure (IOP) generally between 11 and 12 mmHg; a cut-off of 21 mmHg is often applied to define this condition.

Clinical noteAlso called normal or low-pressure glaucoma and is included under open-angle glaucoma for treatment recommendations.

Treatment implicationLowering IOP reduces the risk of developing primary open-angle glaucoma and slows progression, including in normal-tension glaucoma.

Relation to policy coverageNormal-tension glaucoma is considered a form of open-angle glaucoma and is included as a covered indication when criteria are met.