Eysuvis (loteprednol etabonate) — Blue Cross Blue Shield of Alabama

Dry eye disease (dry eye syndrome, keratoconjunctivitis sicca)

Preferred products

Patient has a diagnosis of dry eye disease (dry eye syndrome, keratoconjunctivitis sicca) AND ONE of the following:
- Patient has NOT been previously treated with the requested agent AND ONE of the following:
• Patient has tried and had an inadequate response to at least ONE generic ophthalmic corticosteroid OR
• Patient has an intolerance or hypersensitivity to therapy with generic ophthalmic corticosteroids that is not expected to occur with the requested agent OR
• Patient has an FDA labeled contraindication to ALL generic ophthalmic corticosteroids that is not expected to occur with the requested agent
- Patient has been previously treated with the requested agent AND ALL of the following:
• ONE of the following:
◦ Patient has tried and had an inadequate response to at least ONE generic ophthalmic corticosteroid OR
◦ Patient has an intolerance or hypersensitivity to therapy with generic ophthalmic corticosteroids that is not expected to occur with the requested agent OR
◦ Patient has an FDA labeled contraindication to ALL generic ophthalmic corticosteroids that is not expected to occur with the requested agent
• Patient has had clinical benefit with the requested agent
• Patient’s eyes have been examined under magnification (e.g., slit lamp), and the patient’s intraocular pressure has been evaluated
• Patient does NOT have any FDA labeled contraindications to the requested agent

Patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
Patient has had clinical benefit with the requested agent AND
Patient’s eyes have been examined under magnification (e.g., slit lamp) and intraocular pressure has been evaluated AND
Patient does NOT have any FDA labeled contraindications to the requested agent

3 months