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The Policy VaultThe Policy Vault

Eysuvis — Blue Cross Blue Shield of Kansas

dry eye syndrome

Initial criteria

  • 1. ONE of the following:
  • A. 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:
  • 1. The patient has NOT been previously treated with the requested agent AND ONE of the following:
  • A. The patient has tried and had an inadequate response to at least ONE generic ophthalmic corticosteroid OR
  • B. The patient has an intolerance or hypersensitivity to therapy with generic ophthalmic corticosteroids that is not expected to occur with the requested agent OR
  • C. The patient has an FDA labeled contraindication to ALL generic ophthalmic corticosteroids that is not expected to occur with the requested agent OR
  • 2. The patient has been previously treated with the requested agent AND ALL of the following:
  • A. ONE of the following:
  • 1. The patient has tried and had an inadequate response to at least ONE generic ophthalmic corticosteroid OR
  • 2. The patient has an intolerance or hypersensitivity to therapy with generic ophthalmic corticosteroids that is not expected to occur with the requested agent OR
  • 3. The patient has an FDA labeled contraindication to ALL generic ophthalmic corticosteroids that is not expected to occur with the requested agent AND
  • B. The patient has had clinical benefit with the requested agent AND
  • C. The patient’s eyes have been examined under magnification (e.g., slit lamp), and the intraocular pressure has been evaluated OR
  • B. The patient has another FDA labeled indication for the requested agent OR
  • C. The patient has an indication that is supported in compendia for the requested agent and route of administration AND
  • 2. The 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) AND
  • 3. The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
  • 2. The patient has had clinical benefit with the requested agent AND
  • 3. The patient will NOT be using the requested agent in combination with Verkazia or another target agent AND
  • 4. The patient’s eyes have been examined under magnification (e.g., slit lamp), and the intraocular pressure has been evaluated AND
  • 5. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

3 months initial; 3 months renewal