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travoprost 0.004% — Point32Health

Reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension

Preferred products

  • latanoprost

Initial criteria

  • The patient has had a trial of one (1) Step-1 or Step-2 medication within the previous 180 days as evidenced by a previous paid claim under the prescription benefit administered by the plan
  • OR The patient has had a trial of a Step-1 or Step-2 medication as evidenced by physician documented use, excluding the use of samples
  • OR The patient has a physician documented contraindication or intolerance to a Step-1 medication
  • Note: The plan may cover medications on Step-2 if a patient has received a non-formulary medication, as evidenced by physician documented use, excluding the use of samples