Rho Kinase Inhibitors Prior Authorization Criteria – Medicare Part D

Prior Authorization Criteria for Approval

Initial Evaluation

Rhopressa and Rocklatan will be approved when BOTH of the following are met:

1. The patient has a diagnosis of open-angle glaucoma or ocular hypertension
   AND

2. ONE of the following:

   1. The patient has tried and failed at least ONE generic ophthalmic prostaglandin (e.g., latanoprost)
      OR
   2. The patient has an intolerance or hypersensitivity to ONE generic ophthalmic prostaglandin (e.g., latanoprost)
      OR
   3. The patient has an FDA labeled contraindication to ONE generic ophthalmic prostaglandin (e.g., latanoprost)

Length of approval: 12 months

Renewal Evaluation

Rhopressa and Rocklatan will be approved when ALL of the following are met:

1. The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria
   AND
2. The patient has a diagnosis of open-angle glaucoma or ocular hypertension
   AND
3. The patient has had clinical benefit with the requested medication

Length of approval: 12 months