Restasis MultiDose — Medical Mutual

Dry Eye Conditions due to Ocular Inflammation Associated with Keratoconjunctivitis Sicca (e.g., dry eye syndrome or dry eye disease)

Initial criteria

Patient is age ≥ 16 years
Medication is prescribed by or in consultation with an ophthalmologist, optometrist, or rheumatologist
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 the diagnosis is mild dry eye disease, patient has tried and failed on preservative free artificial tears

Patient is age ≥ 16 years
Medication is prescribed by or in consultation with an ophthalmologist, optometrist, or rheumatologist
Patient has had a beneficial response to therapy (e.g., reduced eye irritation, dryness, red eyes, or burning)

1 year initial, 1 year reauth