Eysuvis — Medical Mutual

Dry Eye Disease

Initial criteria

Patient is age ≥ 18 years; AND
Eysuvis is prescribed by or in consultation with an ophthalmologist, optometrist, or rheumatologist; AND
The prescriber has administered testing for ONE of the following homeostasis markers and the patient has the corresponding result (a, b, c, or d):
a. Schirmer’s test (< 5 mm of wetting over 5 minutes); OR
b. Non-invasive tear breakup time (TBUT) result of 10 seconds or less; OR
c. Osmolarity result of 308 mOsm/L or greater in either eye OR interocular difference of greater than 8 mOsm/L; OR
d. Ocular surface staining result of greater than 5 corneal spots OR greater than 9 conjunctival spots, OR lid margin (2 mm or greater length and 25% or greater width); AND
The patient has tried preservative free artificial tears.

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

1 month initial, 1 month reauth