This policy governs prior authorization and coverage criteria for ophthalmic prostaglandin and related glaucoma eye drop products for Cigna-administered health benefit plans, specifying medically necessary indications, step therapy, and exclusions.
Policy Summary
PayerCigna
PolicyOphthalmic - Glaucoma - Prostaglandins
Policy CodePolicy IP0027
Change TypePreferred-product and step therapy updates
Effective Date
Next Review Date
Key ActionObtain prior authorization; approvals are granted for 1 year when FDA‑approved indications and product-specific preferred-product/step criteria are met.
Policy name was changed from 'Ophthalmic Glaucoma Agents - Prostaglandin Analogs and Rho Kinase Inhibitors' to 'Ophthalmic - Glaucoma - Prostaglandins' with no criteria changes at that time.
Preferred-product criteria for Lumigan and Vyzulta were updated to require four preferred products where previously two were required, and bimatoprost 0.03% was added as a preferred alternative.
Travatan Z preferred-product requirement was changed to require the bioequivalent generic product rather than generic plus one other product.
Rhopressa criteria for Individual and Family Plans were simplified: removed several older trial requirements and added trial of an ophthalmic carbonic anhydrase inhibitor and clarified examples for other classes.
Zioptan and generic tafluprost criteria were split into separate line items and step requirements updated to clarify different step sequences.
10listed ophthalmic prostaglandin products in scope
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Ophthalmic Prostaglandins are considered medically necessary when ONE of the following is met (1 or 2):
FDA-Approved 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.1 year approval
Open-angle glaucoma includes normal-tension (low-tension) glaucoma.
Product-specific Step/Preferred Product Criteria
Product-specific preferred-product and step therapy criteria (varies by plan type — Employer vs Individual & Family):
Iyuzeh (latanoprost 0.005%): Approve when ONE of the following: 1) patient has tried generic latanoprost 0.005% and cannot take it due to a formulation difference in inactive ingredients (e.g., dyes, fillers, preservatives) that the prescriber indicates would cause a significant allergy or serious adverse reaction; OR 2) prescriber documents a significant allergy/sensitivity to benzalkonium chloride (BAK) or other preservatives.
Applies to Employer and Individual & Family plans.
Lumigan (bimatoprost 0.01%): Patient has tried ALL of the following: 1) latanoprost 0.005% ophthalmic solution (Xalatan or generic); 2) bimatoprost 0.03% ophthalmic solution; 3) travoprost 0.004% ophthalmic solution (Travatan Z); AND 4) tafluprost 0.0015% ophthalmic solution (Zioptan).
Trial of a brand version of a generic equivalent counts toward the requirement.
Travatan Z (travoprost 0.004%): Patient has tried the bioequivalent generic travoprost 0.004% ophthalmic solution AND cannot take the brand due to a formulation difference in inactive ingredients that, per the prescriber, would result in a significant allergy or serious adverse reaction.
Travatan Z contains sofZia ionic buffering system (BAK-free).
Vyzulta (latanoprostene bunod 0.024%): Patient has tried ALL of the following: bimatoprost 0.03% ophthalmic solution; latanoprost 0.005% ophthalmic solution (Xalatan); travoprost 0.004% ophthalmic solution (Travatan Z); AND tafluprost 0.0015% ophthalmic solution (Zioptan).
Contains benzalkonium chloride (BAK).
Xalatan / Xelpros (latanoprost products): Xalatan: patient has tried the bioequivalent generic latanoprost 0.005% and cannot take it due to a formulation difference in inactive ingredients. Xelpros: patient has tried generic latanoprost 0.005% and cannot take it due to formulation difference OR has BAK sensitivity (potassium sorbate-preserved emulsion contains no BAK).
Preservative and formulation differences are relevant to product choice.
Zioptan (tafluprost) and generic tafluprost: Zioptan (preservative-free): patient has tried the bioequivalent generic tafluprost and cannot take the brand due to formulation differences. Generic tafluprost: step requirements vary by plan and may require trial of alternative prostaglandins (e.g., latanoprost, bimatoprost, travoprost) to address preservative sensitivities; generic tafluprost may require prior authorization.
Examples and plan-specific variations described in policy.
Rhopressa (netarsudil 0.02%): Patient has tried: 1) ONE ophthalmic prostaglandin analog; AND 2) ONE ophthalmic beta-blocker product; AND 3) either ONE ophthalmic alpha-adrenergic agonist OR ONE ophthalmic carbonic anhydrase inhibitor.
Examples of alternative agents are provided in the policy (e.g., timolol, apraclonidine, dorzolamide).
Rocklatan (netarsudil/latanoprost): Approve when the patient has inability to use Rhopressa and latanoprost (Xalatan) concurrently — i.e., cannot use the single agents together — per prescriber documentation.
May require prior authorization.
Ophthalmic prostaglandin agents are considered not medically necessary when prescribed for any indication other than the FDA‑approved ocular indications covered by this policy. Specifically, use of these agents for non‑ocular or cosmetic purposes is excluded from coverage.
Cosmetic uses of ophthalmic prostaglandins — for example, to promote eyelash growth (such as with products marketed for that purpose) — are expressly excluded and are not covered. Requests or claims for cosmetic indications will be denied as not medically necessary under this policy.
Prior Authorization Required: Prior Authorization is required for benefit coverage of ophthalmic prostaglandins. Approvals are granted for 1 year for FDA‑approved indications (ocular hypertension or open‑angle glaucoma) when product‑specific criteria are met.
All approvals provided for 1 year for FDA‑approved indications (ocular hypertension, open‑angle glaucoma).
PA applies to prescription benefit coverage; cosmetic indications not recommended.
Step Therapy
Product‑Specific Step Requirements
Product‑specific step therapy and prior trial requirements must be documented with the authorization request. Trials of generic or brand equivalents count when specified; prescriber attestation of intolerance, inadequate efficacy, or allergy must be included where applicable.
Iyuzeh (latanoprost 0.005%): trial of latanoprost 0.005% ophthalmic solution (generic Xalatan) OR prescriber documents significant allergy/sensitivity to BAK or other preservatives.
Definitions
Open-angle glaucoma / Normal-tension glaucoma — definition and clinical note
DefinitionOpen-angle glaucoma (includes normal-tension glaucoma) — a disease that damages the optic nerve; lowering intraocular pressure (IOP) reduces risk of disease progression.
Normal-tension glaucoma specificsA form of open-angle glaucoma with presenting IOP generally between 11 and 12 mmHg (a cut-off of 21 mmHg is often applied); also called normal or low-pressure glaucoma.
Clinical significance of IOP reductionReduction of IOP, regardless of pretreatment IOP, reduces the risk of disease progression and may prevent onset of glaucoma in patients with ocular hypertension.
Guideline referenceAmerican Academy of Ophthalmology (2020) includes normal-tension glaucoma in recommendations for care and supports IOP-lowering to slow progression.
Relation to policy scopeOpen-angle glaucoma (including normal-tension glaucoma) is an FDA-approved indication for ophthalmic prostaglandins under this policy.
Background
Topical ophthalmic prostaglandin analogs lower elevated intraocular pressure (IOP) primarily by increasing uveoscleral outflow of aqueous humor; reducing IOP slows progression of optic nerve damage in patients with open‑angle glaucoma and decreases the risk of developing glaucoma in patients with ocular hypertension. For formulary and utilization management, these agents are subject to prior authorization when used for the covered indications and approvals are issued for 1 year when criteria are met.
Revision History
2026-03-01selected_revisionLatest
Selected revision applied to Individual and Family Plans updating preferred-product and step requirements (per chunk 18).
2025-08-01annual_revision
Annual revision updated preferred-product language for Lumigan and Vyzulta and modified Rhopressa criteria for Individual and Family Plans (removed certain trial requirements, added ophthalmic carbonic anhydrase inhibitor and example notes).
2025-01-01
Policy Summary
PayerCigna
PolicyOphthalmic - Glaucoma - Prostaglandins
Policy CodePolicy IP0027
Change TypePreferred-product and step therapy updates
Effective Date
Next Review Date
Key ActionObtain prior authorization; approvals are granted for 1 year when FDA‑approved indications and product-specific preferred-product/step criteria are met.
Lumigan (bimatoprost 0.01%): patient must have tried ALL of: latanoprost 0.005% (Xalatan), bimatoprost 0.03%, travoprost 0.004% (Travatan Z), and tafluprost 0.0015% (Zioptan).
Travatan Z (travoprost 0.004%): trial of bioequivalent generic travoprost 0.004% and prescriber documents inability to take brand due to inactive ingredient differences.
Xalatan (latanoprost 0.005%): trial of bioequivalent generic latanoprost 0.005% and prescriber documents inability to take brand due to inactive ingredient differences.
Xelpros (latanoprost emulsion): trial of generic latanoprost 0.005% solution OR prescriber documents significant allergy/sensitivity to BAK.
Zioptan (tafluprost 0.0015%): trial of bioequivalent generic tafluprost 0.0015% and prescriber documents inability to take brand due to inactive ingredient differences.
Vyzulta (latanoprostene bunod): patient must have tried ALL of bimatoprost 0.03%, latanoprost 0.005% (Xalatan), travoprost 0.004% (Travatan Z), and tafluprost 0.0015% (Zioptan).
Rhopressa (netarsudil 0.02%): patient must have tried ONE ophthalmic prostaglandin analog; additional step requirements may include trials of an ophthalmic beta‑blocker and either an ophthalmic alpha‑agonist OR an ophthalmic carbonic anhydrase inhibitor for certain plans.
Rocklatan (netarsudil/latanoprost): criteria include inability to use single agents (Rhopressa and latanoprost) concurrently as indicated by the prescriber.
Billing Rule
Billing and Plan‑Document Guidance
Billing and Documentation: When submitting claims, use the most appropriate diagnosis and procedure codes effective on the date of service. Requests for authorization and claims must include documentation of trials (dates and products), reason for medication selection (e.g., intolerance, allergy to preservatives, inadequate efficacy), and any prescriber attestations regarding formulation‑related reactions. Claims submitted without covered diagnosis/procedure codes or without required documentation may be denied as not covered.
Include covered diagnosis and procedure codes that align with the policy (ocular hypertension or open‑angle glaucoma).
Attach medication trial history (drug names, dates, duration) and clinical rationale for selecting non‑preferred product (e.g., allergy to BAK, intolerance, inadequate efficacy).
If a brand was tried and is considered equivalent to a generic, document that the trial counts toward step requirements.
Claims lacking covered codes or required documentation will be denied as not covered.
selected_revision
Selected revision updated Employer and Individual/Family preferred-product criteria for Lumigan to require four preferred products and added bimatoprost 0.03% as a preferred alternative (per chunk 17).
2024-09-01annual_revision
Annual revision changed the policy name from 'Ophthalmic Glaucoma Agents - Prostaglandin Analogs and Rho Kinase Inhibitors' to 'Ophthalmic - Glaucoma - Prostaglandins' (no criteria changes at that time).
2024-01-01selected_revision
Selected revision updated preferred-product requirements for Travatan Z and Vyzulta, and removed preferred product requirements for tafluprost for Individual and Family Plans (per chunk 18).
2023-?selected_revision
Updated preferred product criteria splitting Zioptan and generic tafluprost into separate line items and clarified step options for generic tafluprost; clarified generic tafluprost prior authorization may be required (per chunk 19).