Cequa — Medical Mutual

Initial criteria

• Patient age ≥ 18 years
• Cequa is prescribed by or in consultation with an ophthalmologist, optometrist, or rheumatologist
• The provider has administered testing for one of the following homeostasis markers with corresponding results: Schirmer’s test (< 5 mm of wetting over 5 minutes) OR Non-invasive tear breakup time (< 10 s) OR Osmolarity (≥ 308 mOsm/L in either eye or interocular difference of > 8 mOsm/L) OR Ocular surface staining (> 5 corneal spots, > 9 conjunctival spots, or lid margin [≥ 2 mm length and ≥ 25% width])
• If diagnosis is mild dry eye disease, patient tried and failed preservative free artificial tears

Reauthorization criteria

• Patient age ≥ 18 years
• Medication is prescribed by or in consultation with an ophthalmologist, optometrist, or rheumatologist
• Patient has had a beneficial response to therapy, including reduced eye irritation, dryness, red eyes, or burning

Approval duration

1 year initial, 1 year reauth