Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesOphthalmology/OptometryBlue Cross MA topical ocular agents Prior Auth | O…
    Ask Trek AI about this page
    ModifiedBlue Cross Blue Shield - MassachusettsPolicy 426

    Topical ocular hydrating agents and related ophthalmic medications (prior authorization)

    Customize your policy alerts

    Sign up for Blue Cross Blue Shield - Massachusetts Policy 426 alerts

    Get alerted when Policy 426 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Defines prior authorization, quantity limits, coverage criteria, and approval lengths for topical ocular hydrating agents and selected ophthalmic medications for BCBSMA commercial members; applies to providers requesting coverage under the BCBSMA formulary.

    Policy Summary
    PayerBlue Cross Blue Shield - Massachusetts
    PolicyTopical ocular hydrating agents and related ophthalmic medications (prior authorization)
    Policy CodePolicy 426
    Change TypeAdded Tryptyrclarified Miebo diagnosis and updated coverage statuses
    Effective Date
    Next Review Date
    Key ActionSubmit prior authorization with supporting documentation including names/strengths and dates of prior formulary alternatives tried and specifics of treatment failure.
    SourceLink

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    POLICY UPDATE CHANGES

    Clarified diagnosis criteria for Miebo.

    Tryptyr was added to the policy.

    Updated Miebo to preferred brand and updated product coverage statuses (e.g., Lacrisert and Verkazia).

    Clarified FE criteria when using cyclosporin and updated individual consideration section to align with 118E MGL § 51A.

    12 monthsTypical approval length
    2 weeksEysuvis approval length if granted
    6 monthsMiebo / Lacrisert approval length
    multiplePrior auth required
    since 2013Policy active/maintained

    Coverage Criteria for Ophthalmic Agents

    Cyclosporine Single Use Vials

    Covered when ALL of the following are met

    Cyclosporine Single Use Vials medical necessity: 1. Definite diagnosis of moderate or severe keratoconjunctivitis sicca; 2. Prescribed by a board-certified or board-eligible ophthalmologist or optometrist.

    Xiidra

    Covered when ALL of the following are met

    Xiidra medical necessity: 1. Definite diagnosis of moderate or severe dry eye disease (DED); 2. Age 16 or 17 years of age or older (source lists both ages); 3. Prescribed by a board-certified or board-eligible ophthalmologist or optometrist.

    Source lists age as both 16 and 17 in different lines.

    Cequa / Restasis / Tyrvaya / Vevye

    Covered when ALL of the following are met

    Cequa/Restasis/Tyrvaya/Vevye medical necessity: 1. Definite diagnosis of moderate or severe keratoconjunctivitis sicca; 2. Prescribed by a board-certified or board-eligible ophthalmologist or optometrist; 3. Previous use of, or evidence of BCBSMA paid claims for BOTH Xiidra (lifitegrast) AND a cyclosporine formulation.

    Restasis has safety data for ages 16 and older.

    Eysuvis

    Covered when ALL of the following are met

    Eysuvis medical necessity: 1. Definite diagnosis of moderate or severe dry eye disease (DED); 2. Prescribed by a board-certified or board-eligible ophthalmologist or optometrist; 3. Patient does NOT have glaucoma or any active ocular infection.

    If approved, prior authorization will be granted for TWO (2) weeks.

    Miebo

    Covered when ALL of the following are met

    Miebo medical necessity: 1. Definite diagnosis and signs/symptoms of dry eye disease (DED); 2. Age 18 years of age or older; 3. Prescribed by a board-certified or board-eligible ophthalmologist or optometrist.

    If approved, prior authorization will be granted for up to SIX (6) months.

    Lacrisert

    Covered when ALL of the following are met

    Lacrisert medical necessity: 1. Definite diagnosis of severe dry eye disease (DED); 2. Prescribed by a board-certified or board-eligible ophthalmologist or optometrist.

    If approved, prior authorization will be granted for up to SIX (6) months.

    Tryptyr

    Covered when ALL of the following are met

    Tryptyr medical necessity: 1. Definite diagnosis of moderate or severe dry eye disease (DED); 2. Prescribed by a board-certified or board-eligible ophthalmologist or optometrist; 3. Previous use of at least two preferred alternatives (e.g., cyclosporine, Eysuvis, Miebo, Verkazia, Xiidra) with failure or documented clinical rationale for not using the preferred medications.

    Verkazia

    Covered when ALL of the following are met

    Verkazia medical necessity: 1. Definite diagnosis of moderate or severe vernal keratoconjunctivitis (VKC); 2. Age 4 years of age or older.

    Age requirement

    Covered when ALL of the following are met

    Age requirement: Patient is 4 years of age or older.>=4 years

    From policy appendix text.

    For medications that are non-covered on the formulary, the policy requires documentation that the member has had prior treatment failure with, or a contraindication to, at least two covered formulary alternatives when such alternatives are available. Requests that seek coverage of a non-covered product should include supporting clinical information (e.g., chart notes, dates and names/strengths of prior therapies, and details of treatment failure or contraindication) or may be considered through the policy’s individual consideration process when atypical clinical circumstances exist.

    Requests that are based exclusively on manufacturer or office samples do not meet the policy’s coverage criteria. If samples were used, the prescriber must submit additional clinical documentation demonstrating the medical necessity of the requested medication (for example, chart notes describing response to samples, objective findings, or rationale why formulary alternatives are not appropriate) for the request to be considered.

    Provider Requirements, Documentation, and Prior Authorization

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for the ophthalmic medications listed in this policy. Providers must request prior authorization using the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or the paper Formulary Exception/Prior Authorization form. Contact Pharmacy Operations: Phone 1-800-366-7778; Fax 1-800-583-6289. Requests based exclusively on samples will not meet coverage criteria; additional clinical information is required.

    • Use the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or print and fax Form #434.
    • Phone: 1-800-366-7778. Fax: 1-800-583-6289.
    Documentation Required

    Supporting Clinical Documentation Required

    Provider must submit supporting clinical documentation to demonstrate why formulary alternatives were ineffective or contraindicated and to establish that step-therapy or prior-treatment requirements have been met.

    Formulary and Coding References

    Formulary and non-formulary ophthalmic medications referencedmixed
    Xiidralifitegrast
    Eysuvisloteprednol etabonate
    Mieboperfluorohexyloctane
    Verkaziacyclosporine
    Cequacyclosporine
    Restasis (single & multidose)cyclosporine
    Tyrvayavarenicline
    Vevyecyclosporine
    Lacriserthydroxypropyl cellulose
    Tryptyracoltremon

    Definitions and Diagnostic Requirements

    Definite diagnosis requirement
    RequirementPrescriber must document a definite diagnosis (examples: moderate or severe keratoconjunctivitis sicca; moderate or severe dry eye disease; vernal keratoconjunctivitis).
    Prescriber typePrescriptions must be written by a board-certified or board‑eligible ophthalmologist or optometrist (where specified in product criteria).
    Application across productsThe 'definite diagnosis' requirement is applied consistently across multiple product criteria sets (e.g., cyclosporine vials, Xiidra, Cequa/Restasis/Tyrvaya/Vevye, Eysuvis, Tryptyr, Verkazia).
    Severity specificationCriteria explicitly reference 'moderate or severe' disease severity for keratoconjunctivitis sicca, dry eye disease (DED), and vernal keratoconjunctivitis (VKC).
    Documentation purposeUsed to determine medical necessity for coverage of topical ocular agents per the policy criteria.

    Background and Clinical Context

    Dry eye disease (DED) and keratoconjunctivitis sicca are disorders of the tear film and ocular surface often associated with inflammation, and are commonly managed with topical anti-inflammatory and hydrating agents. Therapeutic options referenced in this policy include lifitegrast (Xiidra), multiple cyclosporine formulations (e.g., Cequa, Restasis, Verkazia), topical corticosteroid formulations such as loteprednol etabonate (Eysuvis), perfluorohexyloctane (Miebo), hydroxypropyl cellulose inserts (Lacrisert), and newer agents like Tryptyr (acoltremon). Coverage determinations in this policy depend on a documented definite diagnosis (for example, moderate or severe DED, moderate or severe keratoconjunctivitis sicca, or vernal keratoconjunctivitis), prescriber qualifications, age criteria where applicable, and the patient’s prior treatment history including trials of preferred formulary alternatives.

    Policy Summary
    PayerBlue Cross Blue Shield - Massachusetts
    PolicyTopical ocular hydrating agents and related ophthalmic medications (prior authorization)
    Policy CodePolicy 426
    Change TypeAdded Tryptyrclarified Miebo diagnosis and updated coverage statuses
    Effective Date
    Next Review Date
    Key ActionSubmit prior authorization with supporting documentation including names/strengths and dates of prior formulary alternatives tried and specifics of treatment failure.
    SourceLink
    On This Page
    Coverage Criteria for Ophthalmic AgentsProvider Requirements, Documentation, and Prior AuthorizationFormulary and Coding ReferencesDefinitions and Diagnostic RequirementsBackground and Clinical Context
    • Include the name and strength of formulary alternatives tried and failed, with dates if available.
    • Provide specifics regarding the treatment failure or clinical rationale preventing use of formulary alternatives.
    • We may use prescription claims records to establish prior use; if claims data is unavailable or inadequate, the provider must supply additional documentation.
    Step Therapy

    Formulary Alternatives and Step Requirements

    For non-covered or non-formulary medications, the member must have had previous treatment failure with, or a contraindication to, at least two covered formulary alternatives when available. Prior use of at least two preferred alternatives (or documentation of why they are inappropriate) is required for some products.

    • Examples of preferred alternatives: cyclosporine formulations, Eysuvis (loteprednol), Miebo (perfluorohexyloctane), Verkazia, Xiidra (lifitegrast).
    • Tryptyr and similar non-formulary agents require prior use of at least two preferred alternatives and documentation of failure or contraindication.
    • A higher non-preferred cost share may apply if an exception for a non-formulary/non-covered drug is approved.
    Documentation Required

    Examples of Supporting Documentation

    Acceptable supporting documentation may include chart notes, lab results, clinical notes, prescription claim history, and citations from peer-reviewed literature or recognized drug compendia. Be specific: list names and strengths of formulary alternatives tried, dates of trials, and objective details of treatment failure or contraindication.

    • Clinical notes or supporting clinical statements.
    • Name and strength of alternatives tried and failed (include dates if available) and specifics regarding treatment failure.
    • Clinical literature or references from AHFS, Lexi-Drug, Clinical Pharmacology, Micromedex, or nationally recognized guidelines.
    Dry eye / keratoconjunctivitis sicca definition and guidance
    DefinitionDry eye disease (DED) / keratoconjunctivitis sicca: a disorder of the tear film and ocular surface often associated with inflammation.
    Clinical guidance referencedAmerican Academy of Ophthalmology Preferred Practice Pattern® Guidelines (Dry Eye Syndrome, 2011 and 2013) and relevant product inserts are cited as references.
    Policy usageDED or keratoconjunctivitis sicca must be a 'definite diagnosis' (often specified as moderate or severe) to meet medical necessity criteria for multiple ophthalmic agents (e.g., Xiidra, Eysuvis, cyclosporine products).
    Exclusions/contraindications notedFor certain products (e.g., Eysuvis) criteria also require absence of glaucoma or active ocular infection in addition to a DED diagnosis.