Xiidra — Medical Mutual

Dry Eye Disease

Initial criteria

Patient is age ≥ 17 years; AND
Xiidra is prescribed by or in consultation with an ophthalmologist, optometrist, or rheumatologist; AND
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]); AND
If diagnosis is mild dry eye disease, patient has tried and failed preservative-free artificial tears

Patient is age ≥ 17 years; AND
Medication is prescribed by or in consultation with an ophthalmologist, optometrist, or rheumatologist; AND
Patient has had a beneficial response to therapy, including reduced eye irritation, dryness, red eyes, or burning

1 year initial, 1 year reauth