Tyrvaya — Medical Mutual

Dry Eye Disease (e.g., dry eye syndrome)

Initial criteria

Patient is age ≥ 18 years; AND
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 (≥ 300 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]); AND
Patient has tried artificial tears; AND
The medication is prescribed by or in consultation with an ophthalmologist, optometrist, or rheumatologist

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

initial 1 year; reauth 1 year