Durysta™

Drug - Durysta™ (bimatoprost implant) [Allergan, Inc.]

September 2020

Therapeutic area - Open angle glaucoma or ocular hypertension

Approval criteria

Patient is ≥ 18 years of age AND
Patient has diagnosis of OAG or OHT AND
Medication is prescribed by or in consultation with an ophthalmologist AND
Patient is unable to manage glaucoma using eye drops (e.g., age-related decline in dexterity, visual impairment, etc.) AND
Patient has not previously received treatment with Durysta in the requested eye AND
Patient does not have any of the following contraindications to Durysta:
- Active or suspected ocular or periocular infection
- Diagnosis of corneal endothelial cell dystrophy (e.g., Fuchs’ Dystrophy)
- History of corneal transplantation or endothelial cell transplant (e.g., Descemet’s Stripping Automated Endothelial Keratoplasty [DSAEK])
- Absent or ruptured posterior lens capsule
Hypersensitivity to bimatoprost or to any other component of the product

1 drug delivery system per eye
Durysta should not be administered to an eye that previously received Durysta; therefore, renewal requests for Durysta will not be approved

Durysta must be billed as a medical claim.

MHCP Provider Call Center 651-431-2700 or 800-366-5411