Cequa — Highmark
dry eye disease
Preferred products
- cyclosporine (generic Restasis)
- Xiidra
Initial criteria
- age ≥ 18 years
- diagnosis of dry eye disease (ICD-10: H04.12)
- therapeutic failure, contraindication, or intolerance to artificial tears
- therapeutic failure, contraindication, or intolerance to all of the following plan-preferred products, use must be verified by pharmacy claims or documented chart notes: cyclosporine (generic Restasis) AND Xiidra
Reauthorization criteria
- prescriber attests that the member has experienced positive clinical response to therapy
Approval duration
12 months