Miebo (perfluorohexyloctane) — Blue Cross Blue Shield of Alabama

Dry eye disease (dry eye syndrome, keratoconjunctivitis sicca including Sjögren’s syndrome)

Initial criteria

ONE of the following:
- The 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:
- The patient has previously tried or is currently using aqueous enhancements (e.g., artificial tears, gels, ointments [target agents not included])
OR
- The patient has an intolerance or hypersensitivity to aqueous enhancements
OR
- The patient has an FDA labeled contraindication to ALL aqueous enhancements
OR
- The patient has another FDA labeled indication for the requested agent
AND
- The patient will NOT be using the requested agent in combination with another agent used for dry eye disease (e.g., Restasis, Cequa, Xiidra, Tyrvaya)
AND
- The patient does NOT have any FDA labeled contraindications to the requested agent

- The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
AND
- The patient has had clinical benefit with the requested agent
AND
- The patient will NOT be using the requested agent in combination with another agent used for dry eye disease (e.g., Restasis, Cequa, Xiidra, Tyrvaya)
AND
- The patient does NOT have any FDA labeled contraindications to the requested agent

initial 2 months, renewal 12 months