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cyclosporine (ophthalmic) emulsion 0.1% — Blue Cross Blue Shield of New Mexico

vernal keratoconjunctivitis (VKC)

Preferred products

  • Cequa
  • Restasis
  • Vevye
  • Xiidra

Initial criteria

  • 1. ONE of the following:
  • A. The patient has a diagnosis of vernal keratoconjunctivitis (VKC) AND ONE of the following:
  • 1. ONE of the following:
  • A. The patient has tried and had an inadequate response to combination of a topical ophthalmic mast cell stabilizer AND an antihistamine used in the treatment of VKC OR
  • B. The patient has an intolerance or hypersensitivity to combination of a topical ophthalmic mast cell stabilizer AND an antihistamine used in the treatment of VKC OR
  • C. The patient has an FDA labeled contraindication to ALL topical ophthalmic mast cell stabilizers AND antihistamines OR
  • B. The patient has another FDA labeled indication for the requested agent OR
  • C. The patient has another 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 Cequa, Restasis, Vevye, or Xiidra AND
  • 3. 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
  • SPECIAL CASE (Ohio Fully Insured or HIM Shop (SG) members): 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. The patient has another FDA labeled indication for the requested agent and route of administration OR
  • 2. The patient has another indication that is supported in compendia for the requested agent and route of administration OR
  • 3. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective; accepted study designs may include randomized, double blind, placebo controlled clinical trials (case studies not acceptable)

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 Cequa, Restasis, Vevye, or Xiidra AND
  • 4. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial: BCBSIL 12 months; others 4 months; renewal 12 months