Restasis — 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])
• Patient will NOT use in combination with punctal plug(s)
• Patient has ONE of the following: ▪ Tried and had inadequate response to ONE OTC aqueous enhancement (e.g., artificial tears, gels, ointments) or is currently using an OTC aqueous enhancement OR ▪ An intolerance or hypersensitivity to ONE OTC aqueous enhancement OR ▪ An FDA labeled contraindication to ALL OTC aqueous enhancements
• Patient has another FDA labeled indication or compendia-supported indication
• Patient will NOT use with Verkazia (cyclosporine) or another target agent (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
• If agent is Eysuvis, eyes examined and intraocular pressure evaluated
• No FDA labeled contraindications to requested agent

Approval duration

6 months; Renewal 12 months