Restasis (cyclosporine 0.05% ophthalmic emulsion) — United Healthcare

Initial criteria

• Diagnosis of one of the following: 1) Moderate to severe keratoconjunctivitis sicca OR 2) Dry Eye Disease
• Medication will not be used in combination with another prescription product for dry eye disease or keratoconjunctivitis sicca

Reauthorization criteria

• Patient has demonstrated clinically significant improvement with therapy
• Medication will not be used in combination with another prescription product for dry eye disease or keratoconjunctivitis sicca

Approval duration

12 months