Ophthalmic Prostaglandin Analog Prior Authorization Criteria
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This document governs prior authorization criteria and coverage updates for ophthalmic prostaglandin analog agents for Kentucky Medicaid (Fee-for-Service and MCO) members, effective September 1, 2026. It affects pharmacy providers and prescribers submitting PA requests for the listed agents.
Prior authorization criteria updated for preferred and non-preferred ophthalmic prostaglandin analog agents, including specified diagnosis requirements and trial/failure requirements.
Non-preferred agents now require that the patient has had a ≥30-day trial and failure, allergy, contraindication, or intolerance to ≥2 preferred agents.
Preferred agents require a diagnosis of open-angle glaucoma (and for some agents ocular hypertension is included).
Coverage and Prior Authorization Criteria
Initial and step therapy coverage criteria
Coverage updates effective September 1, 2026:
Diagnosis requirement cited in document
Non-preferred agent coverage
- Required prior trials: Patient has had at least a 30‑day trial and failure of two or more preferred prostaglandin agents (can be from any sub-class)>= 30 days; >= 2 preferred agents
Failure, allergy, contraindication (including potential drug–drug interaction), or intolerance to the preferred agents satisfies this requirement
- Exception to trial requirement: OR the patient has documented allergy, intolerance, contraindication (including potential drug–drug interaction) to the required preferred agents
Documentation of the clinical reason for the exception is required
PA required effective 09/01/2026; see policy for agent list
Effective 09/01/2026, prior authorization (PA) criteria for the ophthalmic prostaglandin analogs listed in this communication have been updated for Kentucky Medicaid (Fee-for-Service and MCO) members. Pharmacy providers and prescribers should follow the revised coverage rules when submitting PA requests. The document specifies that preferred agents (for example, latanoprost; bimatoprost products; tafluprost; Travatan Z; travoprost) are subject to criteria and are covered when the patient has an appropriate diagnosis such as open-angle glaucoma (and for some agents, ocular hypertension is also an included diagnosis).
Requests for non-preferred agents (for example, Vyzulta, Xalatan, Xelpros, Zioptan, Zolymbus) will require documentation that the patient has had a trial and failure, allergy, contraindication (including potential drug–drug interactions), or intolerance to at least two preferred agents. The policy requires that prior trials meet the minimum duration of ≥ 30 days before a non-preferred agent will be approved absent documented contraindication or intolerance.
Agent List, Trials, and Coding
| Latanoprost | Preferred agent (CC, QL) |
| bimatoprost | Preferred agent (Iyuzeh, Lumigan) (CC, QL) |
| tafluprost/PF | Preferred agent (CC, QL) |
| Travatan Z | Preferred agent (CC) |
| Travoprost | Preferred agent (CC) |
| Vyzulta | Non-preferred agent (AE, CC, QL) |
| Xalatan | Non-preferred agent (CC, QL) |
| Xelpros | Non-preferred agent (CC) |
| Zioptan | Non-preferred agent (CC, QL) |
| Zolymbus | Non-preferred agent (CC, QL) |
Prior Authorization, Documentation, and Denial Risk
Prior authorization required (effective 09/01/2026)
Prior authorization (PA) is required for the ophthalmic prostaglandin analog agents listed in this update. This PA requirement is effective September 1, 2026, and applies to the agents identified in the policy.
Step therapy: trial ≥2 preferred agents (≥30 days)
Step therapy applies before coverage of non-preferred prostaglandin analogs: the patient must have trialed and failed at least two preferred agents for a minimum of 30 days each unless an exception applies.
- Trial and failure of >= 2 preferred agents any sub-class
- Each trial must be >= 30 days
- Exceptions allowed for documented allergy, intolerance, contraindication (including drug–drug interactions)
Required documentation for PA requests
Document the clinical justification submitted with PA requests: include the patient’s diagnosis and objective evidence supporting trials/failures or an applicable contraindication, allergy, or intolerance to preferred agents.
- Diagnosis (e.g., open‑angle glaucoma, or ocular hypertension where specified)
- Evidence of trials and failures of preferred agents (duration and outcome)
- Documentation of allergy, intolerance, contraindication or clinically relevant drug–drug interaction when claiming an exception
Denial risk for non‑preferred agents without required documentation
Requests for non-preferred agents are subject to denial if required trials or an approved exception are not documented.
- Denial risk if there is no documentation of ≥30‑day trials and failures of ≥2 preferred agents
- Denial risk if there is no documentation of allergy, intolerance, contraindication, or relevant drug–drug interaction when used to justify bypassing step therapy
Terms and Agent Status
Clinical Background
Ophthalmic prostaglandin analogs are topical medications used to lower intraocular pressure and are commonly prescribed for conditions such as open-angle glaucoma and ocular hypertension. The update clarifies which agents are designated as preferred versus non-preferred for Kentucky Medicaid and establishes step-therapy expectations: prior authorization is required for the listed agents, and coverage of non-preferred products is contingent on documented trials of preferred agents per the criteria effective September 1, 2026.
Policy Changes and Effective Dates
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