Restasis — Blue Cross Blue Shield of Kansas

other FDA labeled indication

Initial criteria

1. ONE of the following:
A. ALL of the following:
1. The patient has a diagnosis of dry eye disease (i.e., dry eye syndrome, keratoconjunctivitis sicca [e.g., Sjögren’s Syndrome]) AND
2. The patient will NOT be using the requested agent in combination with punctal plug(s) AND
3. ONE of the following:
A. The patient has previously tried or is currently using aqueous enhancements (e.g., artificial tears, gels, ointments [target agents not included]) OR
B. The patient has an intolerance or hypersensitivity to aqueous enhancements OR
C. The patient has an FDA labeled contraindication to ALL aqueous enhancements 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

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 does NOT have any FDA labeled contraindications to the requested agent

6 months initial; 12 months renewal