Cequa (cyclosporine) — Blue Cross Blue Shield of New Mexico

Initial criteria

• Diagnosis of dry eye disease (i.e., dry eye syndrome, keratoconjunctivitis sicca [e.g., Sjögren’s Syndrome]) AND BOTH of the following:
• 1. ONE of the following:
• A. BOTH of the following:
• 1. ONE of the following:
• A. Prescriber has stated or submitted documentation that the patient has stage four advanced metastatic cancer and the requested agent is being used to treat the cancer or an associated condition related to stage four advanced metastatic cancer [chart notes required] AND
• 2. Use of the requested agent is consistent with best practices for the treatment of stage four advanced metastatic cancer or associated condition, supported by peer‑reviewed, evidence‑based literature, and approved by the FDA OR
• B. Patient has previously tried or is currently using aqueous enhancements (e.g., artificial tears, gels, ointments [target agents not included]) [chart notes required] OR
• C. Patient has an intolerance or hypersensitivity to aqueous enhancements [chart notes required] OR
• D. Patient has an FDA‑labeled contraindication to ALL aqueous enhancements [chart notes required] AND
• 2. Prescriber is a specialist or has consulted with a specialist related to the requested diagnosis (e.g., ophthalmologist, optometrist, rheumatologist) OR
• Patient has another FDA‑approved indication for the requested agent OR
• Patient has an indication that is supported in compendia for the requested agent and route of administration AND
• 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
• Patient does NOT have any FDA‑labeled contraindications to the requested agent
• Compendia Allowed: AHFS or DrugDex 1, 2a, or 2b level of evidence
• If the member resides in Ohio and the plan is Fully Insured or HIM Shop (SG):
• • Patient does NOT have any FDA‑labeled contraindications to the requested agent AND
• • ONE of the following:
• 1. Patient has another FDA‑labeled indication for the requested agent and route of administration OR
• 2. Patient has another indication supported in compendia for the requested agent and route of administration OR
• 3. Prescriber has submitted TWO peer‑reviewed journal articles (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective; case studies not acceptable [journal articles required]

Approval duration

Miebo, Eysuvis, Tryptyr, Tyrvaya, Cequa, Vevye, Xiidra: 3 months; Restasis: 6 months (BCBSNM); Miebo, Tyrvaya: 2 months; Cequa, Eysuvis, Tryptyr, Vevye, Xiidra: 3 months; Restasis: 6 months (other plans); BCBSIL all agents: 12 months