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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

Quantity limits

  • 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

Billing for Durysta

Durysta must be billed as a medical claim.


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

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