CurrentUnitedHealthcarePolicy N/A

Step therapy for glaucoma agents (travoprost, latanoprostene, tafluprost)

Defines step therapy requirements for coverage of Travatan Z (travoprost), Vyzulta (latanoprostene) and Zioptan (tafluprost) for members with open-angle glaucoma or ocular hypertension; affects pharmacy benefits adjudicated under UnitedHealthcare plans subject to state mandates.

Policy Summary

PayerUnitedHealthcare

PolicyStep therapy for glaucoma agents (travoprost, latanoprostene, tafluprost)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document prior trial or intolerance to latanoprost (or evidence of a ≥90-day supply / 12-month claims history) to secure coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-06-01Policy effective date

12 moClaims look-back

90 dPrior supply threshold

12 moAuthorization duration

Coverage Criteria

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Initial and continuation coverage criteria

Covered when ALL of the following are met:

Step therapy criteria for Travatan Z, Vyzulta, Zioptan: 1) Member has open-angle glaucoma or ocular hypertension (per product indication); AND 2) History of failure, contraindication, or intolerance to latanoprost (generic Xalatan) OR evidence in claims history of prior use of latanoprost in the previous 12 months; OR automated approval may be granted for members with >=90-day supply of the same non-preferred agent in the past 120 days.see node text

Authorization issued for 12 months; state mandates and member benefit plan specifics may affect coverage.

Travatan Z (travoprost) [brand only], Vyzulta (latanoprostene), and Xalatan (latanoprost) [brand only] are typically excluded from coverage except when the policy’s criteria for medical necessity or automated approval rules are met. Coverage for these branded products is subject to plan benefits, applicable federal or state mandates, and other utilization management programs that may apply.

Prior authorization applies to these agents; when criteria are satisfied an authorization is issued for 12 months. The step therapy program and exclusions are effective beginning 2025-06-01 as noted in the program header.

Coding and Claims Look-back

Claims look-back for prior latanoprost

Claims look-back window12 months

PurposeIdentify prior use of latanoprost (generic Xalatan) to allow automated processing of Travatan Z, Vyzulta or Zioptan

Applies toClaims for Travatan Z (travoprost), Vyzulta (latanoprostene), and Zioptan (tafluprost)

Prior supply threshold for continued coverage

Required prior supplyAt least a 90-day supply

Look-back period for supplyWithin the past 120 days

EffectMembers with documented ≥90-day supply in past 120 days are allowed continued coverage of their current therapy

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Travatan Z (travoprost), Vyzulta (latanoprostene) and Zioptan (tafluprost) unless automated claims history criteria are met.

PA applies to Travatan Z, Vyzulta, Zioptan
Automated approval when member has latanoprost claim within prior 12 months
Automated continuation when member has ≥90-day supply of Travatan Z, Vyzulta or Zioptan documented in past 120 days

Step Therapy

Step Therapy Requirement

Step therapy requires trial of latanoprost (generic Xalatan) prior to coverage of Vyzulta or Zioptan. Exceptions to step therapy are described under the coverage criteria (history of failure, contraindication, or intolerance to latanoprost).

Member must trial latanoprost before Vyzulta or Zioptan are approved
Travatan Z subject to same automated-history processing described in PA callout

Documentation Required

Acceptable Documentation

Document medication and claims history to demonstrate prior latanoprost use or qualifying supply thresholds. Acceptable documentation includes pharmacy claims showing a latanoprost fill within the previous 12 months, or evidence of ≥90 days’ supply of Travatan Z, Vyzulta, or Zioptan in the past 120 days to allow continued coverage.

Pharmacy claims showing latanoprost (generic Xalatan) fill in prior 12 months
Claims showing ≥90 days’ supply of Travatan Z, Vyzulta, or Zioptan within past 120 days

Denial Risk

Step Therapy Enforcement / Denial Risk

Claims for Travatan Z, Vyzulta or Zioptan will be denied unless the claim history shows failure, contraindication, or intolerance to latanoprost, or the automated-claims history criteria for prior use/continuation are met.

Denial will occur without documentation of failure/contraindication/intolerance to latanoprost
Automated approvals per documented latanoprost use or prior 90-day supply exception may prevent denial

Background

Bimatoprost, travoprost, latanoprost, latanoprostene and tafluprost are topical ophthalmic prostaglandin analogues used to lower elevated intraocular pressure in patients with open‑angle glaucoma or ocular hypertension. These agents are commonly prescribed as once‑daily eye drops and are a standard first‑line class for reducing intraocular pressure.

This policy’s utilization management approach encourages initiation with the preferred, typically lower‑cost agent latanoprost (generic Xalatan) prior to coverage of higher‑cost branded prostaglandin analogues. Documentation of prior trial, intolerance, or contraindication to latanoprost—or qualifying automated claims history—are accepted to establish medical necessity for Travatan Z, Vyzulta, or Zioptan.

Definitions

Step therapy (program description)

DefinitionStep therapy is a utilization management program that requires trial of a preferred (typically lower‑cost) medication prior to coverage of a non‑preferred agent.

Program requirement (Glaucoma Agents)Member must try latanoprost (generic Xalatan) before coverage of Vyzulta or Zioptan; Travatan Z, Vyzulta or Zioptan approved only with history of failure, contraindication, or intolerance to latanoprost.

Automated approvalsClaims with documented latanoprost use in the previous 12 months will automatically process for Travatan Z, Vyzulta or Zioptan.

Continuation allowanceMembers with ≥90-day supply of the same non‑preferred agent in the past 120 days are allowed continued coverage.

Initial Therapy Criteria

Initial therapy

Initial coverage requires trial or documented intolerance to preferred agent.

Initial therapy criteria: Prior trial of latanoprost (generic Xalatan) is required unless there is documentation of failure, contraindication, or intolerance to latanoprost. Automated approvals may be granted based on claims history showing prior latanoprost use within the previous 12 months.see text

Authorization issued for 12 months when approved.

Continuation Therapy Criteria

Continuation therapy rules

Continuation of current therapy allowed when prior use is documented in claims history.

Continuation allowance: Members with evidence of a prescription for latanoprost in claims history within the previous 12 months will have claims for Travatan Z, Vyzulta or Zioptan automatically process. Members who received at least a 90-day supply of Travatan Z, Vyzulta or Zioptan in the past 120 days will be allowed continued coverage.90 days/120 days

Authorization duration when issued: 12 months; state mandates and benefit specifics may apply.

Step Therapy Requirements

Step	Requirement	Coverage effect
1	Member must have trial of latanoprost (generic Xalatan) prior to coverage of Travatan Z (travoprost), Vyzulta (latanoprostene) or Zioptan (tafluprost); or documentation of failure, contraindication, or intolerance to latanoprost	Coverage approved only after requirement met (approval issued for 12 months)
Automated approval path	Claim will automatically process if there is a prescription for latanoprost in claims history within the previous 12 months	Approved (automated) when prior latanoprost use documented
Continuation allowance	Members with ≥90‑day supply of Travatan Z, Vyzulta, or Zioptan in the past 120 days (per claims) will be allowed continued coverage	Continued coverage allowed