Restasis MultiDose — United Healthcare
Moderate to severe dry eye disease
Preferred products
- Miebo
- Restasis single dose vials
- Xiidra
Initial criteria
- Diagnosis of one of the following: Moderate to severe keratoconjunctivitis sicca OR Moderate to severe dry eye disease
- NOT prescribed to manage dry eyes peri-operative elective eye surgery (e.g.: LASIK)
- History of failure, contraindication or intolerance to two of the following: Miebo, Restasis single dose vials, Xiidra
- Medication will NOT be used in combination with another prescription product for dry eye disease or keratoconjunctivitis sicca (e.g., Miebo, Restasis single dose-vials, Tyrvaya, Xiidra)
- Prescribed by or in consultation with one of the following: Ophthalmologist OR Optometrist OR Rheumatologist
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 (e.g., Miebo, Restasis single dose-vials, Tyrvaya, Xiidra)
Approval duration
12 months