Eysuvis — Blue Cross Blue Shield of Alabama

Initial criteria

• Patient has a diagnosis of dry eye disease (i.e., dry eye syndrome, keratoconjunctivitis sicca [e.g., Sjögren’s Syndrome]) AND ONE of the following scenarios:
• If patient NOT previously treated with requested agent: ▪ Tried and had an inadequate response to ONE generic ophthalmic corticosteroid OR ▪ An intolerance or hypersensitivity to ONE generic ophthalmic corticosteroid that is NOT expected to occur with requested agent OR ▪ An FDA labeled contraindication to ALL generic ophthalmic corticosteroids that is NOT expected to occur with requested agent
• If patient previously treated with requested agent: ▪ Tried and had an inadequate response to ONE generic ophthalmic corticosteroid OR ▪ An intolerance or hypersensitivity to ONE generic ophthalmic corticosteroid that is NOT expected to occur with requested agent OR ▪ An FDA labeled contraindication to ALL generic ophthalmic corticosteroids that is NOT expected to occur with requested agent 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 evaluated
• Patient may also qualify if there is another FDA labeled indication or compendia-supported indication
• Patient will NOT use in combination with Verkazia (cyclosporine) or another target agent in this program (e.g., Cequa, Eysuvis, Miebo, Restasis, Tryptyr, Tyrvaya, Vevye, Xiidra)
• No FDA labeled contraindications to requested agent

Reauthorization criteria

• Patient previously approved through plan’s prior authorization process
• Patient has had clinical benefit with the requested agent
• Patient will NOT be using agent with Verkazia or other target agent in this program
• Eyes examined under magnification and intraocular pressure evaluated
• No FDA labeled contraindications to requested agent

Approval duration

3 months; Renewal 3 months