Tyrvaya — Blue Cross Blue Shield of Oklahoma

Initial criteria

• 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 BOTH of the following:
• 1. ONE of the following:
• A. BOTH of the following:
• 1. ONE of the following:
• A. The prescriber has stated that the patient has stage four advanced metastatic cancer and the requested agent is being used to treat the cancer OR
• B. The prescriber has submitted documentation that the patient has stage four advanced metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes required] AND
• 2. The 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 FDA-approved OR
• B. The 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. The patient has an intolerance or hypersensitivity to aqueous enhancements [chart notes required] OR
• D. The patient has an FDA labeled contraindication to ALL aqueous enhancements [chart notes required] AND
• 2. The prescriber is a specialist or has consulted with a specialist related to the requested diagnosis (e.g., ophthalmologist, optometrist, rheumatologist) OR
• B. The patient has another FDA approved 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 (Cequa, Eysuvis, Miebo, Restasis, Tryptyr, Tyrvaya, Vevye, Xiidra) AND
• 3. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

varies by plan: BCBSIL all agents 12 months; BCBSMT/BCBSNM Miebo, Eysuvis, Tryptyr, Tyrvaya, Cequa, Vevye, Xiidra 3 months and Restasis 6 months; all other plans Miebo and Tyrvaya 2 months, Cequa, Eysuvis, Tryptyr, Vevye, Xiidra 3 months, Restasis 6 months