Tyrvaya — Blue Cross Blue Shield of Montana

Initial criteria

• Diagnosis of dry eye disease (dry eye syndrome, keratoconjunctivitis sicca [e.g., Sjögren’s Syndrome]) AND BOTH of the following:
• • The patient has previously tried or is currently using aqueous enhancements (artificial tears, gels, ointments) [chart notes required] OR has intolerance or hypersensitivity to aqueous enhancements [chart notes required] OR has an FDA labeled contraindication to ALL aqueous enhancements [chart notes required] OR the prescriber has provided documentation for stage four advanced metastatic cancer use per criteria
• • The prescriber is a specialist or has consulted with a specialist related to the requested diagnosis (ophthalmologist, optometrist, rheumatologist)
• OR The patient has another FDA approved indication for the requested agent
• OR The patient has an indication that is 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 in this program (Cequa, Eysuvis, Miebo, Restasis, Tryptyr, Tyrvaya, Vevye, Xiidra)
• AND The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

3 months (Miebo, Eysuvis, Tryptyr, Tyrvaya, Cequa, Vevye, Xiidra for BCBSMT/BCBSNM); 6 months (Restasis BCBSMT/BCBSNM); 12 months (BCBSIL); others: 2–6 months per plan