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Restasis Multidose (cyclosporine 0.05% ophthalmic emulsion) — Cigna

Dry Eye Conditions due to Systemic Inflammatory Diseases

Initial criteria

  • Dry Eye Disease: Approve if patient age ≥ 16 years.
  • Dry Eye Conditions due to Systemic Inflammatory Diseases: Approve if patient age ≥ 16 years.
  • Dry Eye Conditions due to Ocular Surface Diseases: Approve if patient age ≥ 16 years.

Approval duration

1 year