ModifiedMass General Brigham Health PlanPolicy N/A

Glaucoma Step Therapy: Bimatoprost 0.01% Iyuzeh Rocklatan Rhopressa Tafluprost 0.0015% Travoprost 0.004% Effective 02/01/2025_

Defines pharmacy step-therapy sequencing and prior-authorization requirements for specified glaucoma eye drop products (first-, second-, third-line) across Mass General Brigham Health Plan lines of business; includes adjudication rules at point-of-sale, exception rules for new members, and approval durations.

Policy Summary

PayerMass General Brigham Health Plan

PolicyGlaucoma Step Therapy: Bimatoprost 0.01% Iyuzeh Rocklatan Rhopressa Tafluprost 0.0015% Travoprost 0.004% Effective 02/01/2025_

Policy CodePolicy N/A

Change TypeMODIFIED

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionIf the prescription does not meet the initial step therapy requirements at point-of-sale, submit a prior authorization request indicating the applicable clinical override (inadequate response or adverse effect) or new-to-plan status.

SourceLink

POLICY UPDATE CHANGES

Iyuzeh (latanoprost) added to criteria as third-line agent.

Approval criteria updated to mirror automated step requirements.

Removed Lumigan and Travatan as products are non-formulary and replaced by generics.

3Step levels (First/Second/Third)

180 daysAdjudication lookback period

36 monthsStandard authorization duration

Summary of changes and impact

This bulletin updates the glaucoma topical ocular hypotensive step-therapy policy to enforce a latanoprost-first sequencing (latanoprost as first-line) across the pharmacy benefit. Prescriptions that meet the step criteria adjudicate automatically at the point-of-sale; if the claim does not meet step requirements the claim will deny and a prior authorization (PA) is required. New members who were receiving a second- or third-line agent within the last 90 days (excluding samples and manufacturer patient assistance programs) may be authorized under the new-member exception rules. When approved, authorizations are granted for 36 months.

Key thresholds and headline stats

Fill-history lookback180 days

New-to-plan exception window90 days

Approval duration36 months

Step levels3

Step-therapy coverage criteria

Initial Step-Therapy Requirements

Covered when meeting the step sequencing and fill-history rules:

ALL of the following

First-Line: Medications listed on first-line are covered without prior-authorization
First-line = Latanoprost 0.005%
Second-Line: Second-line medications will pay if the member has filled a first-line medication or a second-line medication within the past 180 days180 days
Second-line = Bimatoprost 0.01%, Travoprost 0.004%, Tafluprost 0.0015%
Third-Line: Third-line medications will pay if the member has filled a second-line medication or a third-line medication within the past 180 days180 days

Covered drug groups and product status

Covered drug list by step (pharmacy benefit)NDCCovered

Latanoprost 0.005%	First-line agent covered without prior-authorization
Bimatoprost 0.01%	Second-line agent
Travoprost 0.004%	Second-line agent
Tafluprost 0.0015%	Second-line agent
Rhopressa (netarsudil)	Third-line agent
Rocklatan (netarsudil/latanoprost)	Third-line agent
Iyuzeh (latanoprost)	Third-line agent (added as third-line in 12/13/2023 update)

What providers must do

Prior Authorization

Submit PA when step requirements not met

If a prescription denies at point-of-sale because it does not meet the step requirements, submit a prior authorization request. In the PA indicate the applicable clinical override (inadequate response or adverse effect) or that the member is new to the plan within the exception window.

Claims that do not meet step criteria will deny at point-of-sale and require PA.
PA must state the clinical override (inadequate response or side effect) or new-to-plan status.

Documentation Required

Document prior treatment and reasons for failure

For PA of second- or third-line agents, document which prior agent failed and whether the failure was due to inadequate response or a side effect. Include the specific prior agent and the reason for failure to support the clinical override.

Background and references

Purpose: To promote use of latanoprost as the first-line prostaglandin analogue and to define automated adjudication and prior-authorization behavior for higher-line glaucoma agents. Scope: Applies to Mass General Brigham Health Plan pharmacy benefit and defines step-therapy sequencing (first-, second-, third-line), point-of-sale adjudication, new-member exception rules, and standard authorization duration.

Evidence: Prescribing information references cited in the policy include Iyuzeh (latanoprost) prescribing information (April 2024), Lumigan (bimatoprost) prescribing information (June 2024), Rhopressa (netarsudil) prescribing information (March 2019), Rocklatan (netarsudil/latanoprost) prescribing information (June 2020), Travatan Z (travoprost) prescribing information (May 2020), Zioptan (tafluprost) prescribing information (May 2023), and Xalatan (latanoprost) prescribing information (May 2023).

Definitions:

• First-line: Latanoprost 0.005% — covered without prior-authorization.

• Second-line: Bimatoprost 0.01%, Travoprost 0.004%, Tafluprost 0.0015% — will pay if the member has filled a first-line or a second-line medication within the past 180 days; otherwise PA required with documented inadequate response or side effect to one first-line or one second-line agent.

• Third-line: Rhopressa (netarsudil), Rocklatan (netarsudil/latanoprost), Iyuzeh (latanoprost) — will pay if the member has filled a second-line or a third-line medication within the past 180 days; otherwise PA required with documented inadequate response or side effect to one second-line or one third-line agent.

Document changes and effective dates

12/13/2023added

Iyuzeh (latanoprost) added to criteria as third-line agent; removed Lumigan and Travatan as products are non-formulary and replaced by generics. (Noted in 12/13/2023 update; initial effective date 02/01/2024.)

11/13/2024revisedLatest

Approval criteria updated to mirror automated step requirements; update noted 11/13/2024 with effective date 02/01/2025.

Policy Summary

PayerMass General Brigham Health Plan

PolicyGlaucoma Step Therapy: Bimatoprost 0.01% Iyuzeh Rocklatan Rhopressa Tafluprost 0.0015% Travoprost 0.004% Effective 02/01/2025_

Policy CodePolicy N/A

Change TypeMODIFIED

Effective DateFeb 1, 2025

Next Review DateN/A

SourceLink

On This Page

Third-line = Rhopressa, Rocklatan, Iyuzeh

Sequencing notes: Prescriptions that meet the initial step therapy requirements will adjudicate automatically at the point of sale; otherwise the claim will deny and PA is required.

See overview and review history for formulary updates

Authorization exceptions for new-to-plan members

Covered when ALL of the following are met:

New-to-plan exception: Member is new to the plan within the last 90 days90 days

Member may be authorized when currently receiving treatment with a second- or third-line agent

Current receipt requirement: Agent must be currently received (excludes samples and manufacturer's patient assistance programs)

Products obtained as samples or via manufacturer patient assistance programs are excluded

Clinical override criteria for members who do not meet automated step requirements

Approval may be granted when ONE of the following is met:

Second-line clinical override: Approval of a second-line medication when the member has had an inadequate response or side effect to one first-line medication OR one second-line medication

Document which agent failed and reason (inadequate response or side effect)

Third-line clinical override: Approval of a third-line medication when the member has had an inadequate response or side effect to one second-line medication OR one third-line medication

Document which agent failed and reason (inadequate response or side effect)

Limitations / Duration

Authorization length: Approvals will be granted for 36 months36 months

Authorization length fixed at 36 months

Second-line approval: document failure of one first-line agent OR one second-line agent.
Third-line approval: document failure of one second-line agent OR one third-line agent.