Restasis — Highmark
dry eye disease
Preferred products
- generic cyclosporine ophthalmic emulsion
Initial criteria
- age ≥ 16 years
- diagnosis of dry eye disease (ICD-10: H04.12)
- request meets one of the following: (a) Restasis multidose – member has contraindication or intolerance to plan-preferred generic cyclosporine ophthalmic emulsion that would not be expected with the brand product; OR (b) Restasis single dose – member has contraindication or intolerance to generic cyclosporine ophthalmic emulsion that would not be expected with the brand product; use must be verified by pharmacy claims or documented chart notes
Reauthorization criteria
- prescriber attests that the member has experienced positive clinical response to therapy
- request meets one of the following: (a) Restasis multidose – member has contraindication or intolerance to plan-preferred generic cyclosporine ophthalmic emulsion that would not be expected with the brand product; OR (b) Restasis single dose – member has contraindication or intolerance to generic cyclosporine ophthalmic emulsion that would not be expected with the brand product; use must be verified by pharmacy claims or documented chart notes
Approval duration
12 months