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Eysuvis — Blue Cross Blue Shield of Illinois

keratoconjunctivitis sicca

Initial criteria

  • ONE of the following:
  • A. Diagnosis of dry eye disease (dry eye syndrome, keratoconjunctivitis sicca, Sjögren’s Syndrome) AND BOTH of the following:
  • 1. ONE of the following:
  • A. The prescriber has stated or documented that the patient has stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR
  • B. The prescriber has documented that the patient has stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer AND
  • 2. The use of the requested agent is consistent with best practices for stage four advanced, metastatic cancer or an associated condition, supported by peer‑reviewed, evidence‑based literature, and approved by the FDA OR
  • B. The patient has previously tried or is currently using aqueous enhancements (artificial tears, gels, ointments) [chart notes required] OR
  • C. The patient has intolerance or hypersensitivity to aqueous enhancements [chart notes required] OR
  • D. The patient has an FDA labeled contraindication to ALL aqueous enhancements [chart notes required] AND
  • 2. The prescriber is a specialist or has consulted with a specialist related to the requested diagnosis (ophthalmologist, optometrist, rheumatologist) OR
  • B. The patient has another FDA approved indication for the requested agent OR
  • C. The patient has an indication supported in compendia for the requested agent and route of administration AND
  • The patient will NOT be using the requested agent in combination with Verkazia (cyclosporine) or another target agent (Cequa, Eysuvis, Miebo, Restasis, Tryptyr, Tyrvaya, Vevye, Xiidra) AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent
  • Compendia allowed: AHFS or DrugDex 1, 2a, or 2b level of evidence
  • Alternate Ohio criteria: member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
  • A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
  • B. ONE of the following:
  • 1. Another FDA labeled indication for the agent and route OR
  • 2. Another indication supported in compendia OR
  • 3. Two peer‑reviewed journal articles supporting use as generally safe and effective (randomized double‑blind placebo‑controlled trials; case studies not acceptable)

Approval duration

12 months (BCBSIL); 3–6 months (BCBSMT/BCBSNM variable by agent); 2–6 months (other plans by agent)