Xiidra (lifitegrast) — Blue Cross Blue Shield of Texas

Initial criteria

• ONE of the following:
• A. The patient has a diagnosis of dry eye disease (dry eye syndrome, keratoconjunctivitis sicca including 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 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 such 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 an associated condition and supported by peer-reviewed, evidence-based literature and approved by the FDA OR
• B. The patient has previously tried or is currently using aqueous enhancements (e.g., artificial tears, gels, ointments) [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.
• Compendia Allowed: AHFS or DrugDex 1, 2a, or 2b level of evidence.
• Additional pathway for Ohio fully insured or HIM Shop (SG) plans:
• 1. The member resides in Ohio AND
• 2. The plan is Fully Insured or HIM Shop (SG) AND 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 peer-reviewed articles supporting the proposed use as generally safe and effective (JAMA, NEJM, or Lancet; case studies not acceptable)

Approval duration

2–12 months (varies by plan and drug: BCBSIL 12 months; others 2–6 months; details per drug/plan specification)