Eysuvis — Highmark
dry eye syndrome
Initial criteria
- age ≥ 18 years
- diagnosis of dry eye syndrome (ICD-10: H04.12)
- therapeutic failure, intolerance, or contraindication to artificial tears
Reauthorization criteria
- prescriber attests that the member has experienced positive clinical response to therapy
- prescriber attests that the member continues to have symptoms of dry eye syndrome (ICD-10: H04.12)
- prescriber attests that member has been reexamined under magnification such as a slit lamp
- prescriber attests that the member’s intraocular pressure measurement has been reevaluated
Approval duration
1 month