Vevye — 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: ▪ Tried and had an inadequate response to ONE over-the-counter (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 OR Patient has another FDA labeled indication for the requested agent and route of administration OR Patient has an indication supported in compendia for the requested agent and route of administration
• Patient will NOT be using the requested agent in combination with Verkazia (cyclosporine) or another target agent in this program (e.g., Cequa, Eysuvis, Miebo, Restasis, Tryptyr, Tyrvaya, Vevye, Xiidra)
• Patient does NOT have any FDA labeled contraindications to the 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 the requested agent in combination with Verkazia (cyclosporine) or another target agent in this program (e.g., Cequa, Eysuvis, Miebo, Restasis, Tryptyr, Tyrvaya, Vevye, Xiidra)
• If agent is Eysuvis, eyes examined under magnification and intraocular pressure evaluated
• Patient does NOT have any FDA labeled contraindications

Approval duration

Miebo, Tyrvaya 2 months; Cequa, Tryptyr, Vevye, Xiidra 3 months; Renewal 12 months