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    v1.0.28
    OpenPayerPolicy UpdatesOphthalmology/OptometryBlue Cross MA topical ocular agents Prior Auth | O…
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    ModifiedBlue Cross Blue Shield - MassachusettsPolicy 426

    Topical ocular hydrating agents and related ophthalmic medications prior authorization

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    This policy governs prior authorization, quantity limits, and medical necessity criteria for topical ocular hydrating agents and selected ophthalmic medications for commercial BCBSMA members with formulary prescription coverage.

    Policy Summary
    PayerBlue Cross Blue Shield - Massachusetts
    PolicyTopical ocular hydrating agents and related ophthalmic medications prior authorization
    Policy CodePolicy 426
    Change TypeMaterial updates — new agents added and formulary status changes (Tryptyr addedMiebo preferredLacrisert addedVevye non-covered)
    Effective Date
    Last ReviewJan 15, 2026
    Next Review Date
    Key ActionSubmit prior authorization requests with supporting documentation (chart notes, names/strengths and dates of alternative trials, and clinical rationale) via phone, fax, or the Massachusetts PA form.
    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

    Tryptyr added to the policy.

    Miebo updated to preferred brand and QCD added to Lacrisert and Verkazia; formatting updated.

    Lacrisert (hydroxypropyl cellulose) added to the policy.

    Vevye (cyclosporine) added as non-covered.

    12 monthsstandard approval length
    2 weeksEysuvis approval
    up to 6 monthsMiebo/Lacrisert approval
    >=2013policy in effect since
    15+history actions
    Yessamples excluded

    Coverage and Medical Necessity Criteria

    Cyclosporine Single Use Vials - Initial criteria

    Covered when ALL of the following are met

    Cyclosporine Single Use Vials: 1. Definite diagnosis of moderate or severe keratoconjunctivitis sicca; 2. (see source — item 2 not present in extracted text); 3. Prescribed by a board-certified or board-eligible ophthalmologist or optometrist.

    Source text shows item 2 is missing in the extract.

    Xiidra - Initial criteria

    Covered when ALL of the following are met

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

    Document contains conflicting age lines (16 and 17 years).

    Cyclosporine and related agents - Initial criteria with prior use requirement

    Covered when ALL of the following are met

    Cequa/Restasis/Tyrvaya/Vevye: 1. Definite diagnosis of moderate or severe keratoconjunctivitis sicca; 2. (see source — item 2 not present in extracted text); 3. Prescribed by a board-certified or board-eligible ophthalmologist or optometrist; 4. Previous use of, or evidence of BCBSMA paid claims for BOTH Xiidra (lifitegrast) AND cyclosporine (all formulations).

    Source notes Restasis has safety data to include ages 16 and older.

    Eysuvis - Initial criteria and approval length

    Covered when ALL of the following are met

    Eysuvis: 1. Definite diagnosis of moderate or severe dry eye disease (DED); 2. (see source — item 2 not present in extracted text); 3. Prescribed by a board-certified or board-eligible ophthalmologist or optometrist; 4. The patient does NOT have glaucoma or any active ocular infection.2 weeks

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

    Miebo and Lacrisert - Initial criteria

    Covered when ALL of the following are met

    Miebo and Lacrisert: 1. Definite diagnosis of severe dry eye disease (DED); 2. Age 18 years of age or older (source contains repeated/conflicting age lines).up to 6 months

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

    Tryptyr - Initial criteria with prior agent requirement

    Covered when ALL of the following are met

    Tryptyr: 1. Definite diagnosis of moderate or severe dry eye disease (DED); 2. (see source — item 2 not present in extracted text); 3. Prescribed by a board-certified or board-eligible ophthalmologist or optometrist; 4. Previous use of at least two preferred alternatives (e.g., cyclosporine, Eysuvis, Miebo, Verkazia, Xiidra) with documented failure or clinical rationale for not using the preferred medications.

    Policy history indicates Tryptyr was added in recent update.

    Verkazia - Initial criteria

    Covered when ALL of the following are met

    Verkazia: 1. Definite diagnosis of moderate or severe vernal keratoconjunctivitis (VKC); 2. (other items not present in this extract)

    Additional prescriber or age items present elsewhere in the policy may apply.

    For medications designated as non-covered, the policy requires documentation that the member has had a prior treatment failure with, or a contraindication to, at least two covered formulary alternatives when those alternatives are available. If an exception is requested for a non-formulary or non-covered drug and approved, a higher non-preferred cost share may apply. Providers must submit supporting clinical documentation (for example, chart notes or lab results) to show that the member meets all approval criteria for the requested exception.

    Requests that are based exclusively on the use of drug samples will not meet the coverage criteria for an exception. To be considered, prior authorization or an exception request must include additional clinical information demonstrating medical necessity beyond evidence of sample use.

    When submitting an exception or prior authorization request that references sample use, providers should include comprehensive supporting documentation to allow individual consideration. Useful materials include clinical notes or statements, the names and strengths of formulary alternatives tried and failed (with specifics), and relevant literature or drug compendia references. Providers may submit this information via the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or print and fax form #434, or by calling, faxing, or mailing clinical information to Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department. Requests relying only on samples will be declined unless supplemented with the additional clinical evidence described above.

    Formulary Listings, Codes, and Age/Approval Details

    Formulary ophthalmic medications listedmixed
    Eysuvisloteprednol etabonate
    Xiidralifitegrast
    Mieboperfluorohexyloctane
    Verkaziacyclosporine
    Cyclosporine single use vialscyclosporine (single use)
    Lacriserthydroxypropyl cellulose
    Restasis single use vialscyclosporine single use
    Restasis multidosecyclosporine multidose
    Cequacyclosporine
    Tryptyracoltremon
    1–10 of 12
    1/2
    Age limits and approval-length highlights
    Standard approval lengthStandard prior authorization length: 12 months (policy default)
    Eysuvis approval lengthIf approved, prior authorization granted for 2 weeks.
    Xiidra age limitAge 16 or 17 years or older (document lists both age 16 and age 17 in separate lines).
    Miebo / Lacrisert age limitTypically age 18 years or older for Miebo and Lacrisert (document contains repeated/conflicting age lines including an anomalous 'age 4' entry).
    Restasis/Cequa age noteRestasis safety data includes ages 16 years and older.

    Prior Authorization, Documentation, and Submission Instructions

    Prior Authorization

    Prior Authorization Submission

    Prior authorization is required for multiple topical ocular agents (see formulary). Providers must request prior authorization before coverage: call Pharmacy Operations at 1-800-366-7778, fax forms to 1-800-583-6289, mail to Blue Cross Blue Shield of Massachusetts, Pharmacy Operations Department, 25 Technology Place, Hingham, MA 02043, or submit the Massachusetts Standard eForm for Medication Prior Authorization Requests (Form #434) available at: https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/023%20E%20Form%20medication%20prior%20auth%20instruction%20prn.pdf. Use the designated Formulary Exception/Prior Authorization form when applicable.

    • Phone: 1-800-366-7778
    • Fax: 1-800-583-6289
    • Mail: Pharmacy Operations Dept., 25 Technology Place, Hingham, MA 02043
    • eForm: Massachusetts Standard Form for Medication Prior Authorization Requests (Form #434)
    Denial Risk

    Background and Scope

    This policy governs prior authorization, quantity limits, and medical necessity criteria for topical ocular hydrating agents and selected ophthalmic medications used to treat moderate to severe dry eye disease (keratoconjunctivitis sicca) and related conditions such as vernal keratoconjunctivitis (VKC). It defines prescriber qualifications, age limits for specific agents, and the clinical documentation required to demonstrate medical necessity for covered and non-covered products.

    Diagnostic and Term Definitions

    Definite diagnosis — required confirmed diagnosis
    Required diagnosis (most products)Definite diagnosis of moderate or severe keratoconjunctivitis sicca (dry eye disease) is required for coverage of most cyclosporine and lifitegrast products.
    Verkazia specific diagnosisDefinite diagnosis of moderate or severe vernal keratoconjunctivitis (VKC) required for Verkazia.
    Prescriber requirementPrescribed by a board-certified or board-eligible ophthalmologist or optometrist (required for listed products).
    Prior-use requirement for some agentsCoverage of Cequa, Restasis, Tyrvaya, and Vevye requires previous use of, or evidence of BCBSMA paid claims for BOTH Xiidra (lifitegrast) AND cyclosporine (all formulations).
    Keratoconjunctivitis sicca / Dry Eye Syndrome — definition and guideline reference
    Definition

    Policy Revision History

    2026-01-15policy_updateLatest

    Tryptyr added to the policy (November P&T action).

    2026-01policy_update

    Miebo updated to preferred brand; QCD added to Lacrisert and Verkazia; formatting updated.

    2024-07policy_update
    Policy Summary
    PayerBlue Cross Blue Shield - Massachusetts
    PolicyTopical ocular hydrating agents and related ophthalmic medications prior authorization
    Policy CodePolicy 426
    Change TypeMaterial updates — new agents added and formulary status changes (Tryptyr addedMiebo preferredLacrisert addedVevye non-covered)
    Effective Date
    Last ReviewJan 15, 2026
    Next Review Date
    Key ActionSubmit prior authorization requests with supporting documentation (chart notes, names/strengths and dates of alternative trials, and clinical rationale) via phone, fax, or the Massachusetts PA form.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaFormulary Listings, Codes, and Age/Approval DetailsPrior Authorization, Documentation, and Submission InstructionsBackground and ScopeDiagnostic and Term DefinitionsPolicy Revision History

    Denial Triggers — Documentation and Sample-Based Requests

    Coverage requires documentation of prior use or clinical rationale for not using preferred alternatives. Failure to document required medication trials (names, strengths, dates if available) or to provide a clear clinical rationale for why preferred agents were not appropriate may result in denial. Requests based exclusively on samples will be denied; additional clinical information from the prescribing provider must be submitted to support medical necessity.

    • Provider must list name and strength of alternatives tried and failed, and specifics of treatment failure (include dates when available)
    • Requests based solely on samples are not sufficient for approval
    • If prescription claims do not establish prior use, provider must submit additional documentation
    Step Therapy

    Step Therapy and Prior-Use Requirements

    Step therapy requires previous use of preferred alternatives or documentation of clinical rationale for not using them. For medications covered under this policy, approval generally requires prior use of at least two preferred alternatives (examples include cyclosporine formulations, Eysuvis, Miebo, Verkazia, and Xiidra) with documented failure, intolerance, contraindication, or an adequate clinical explanation why these agents are not appropriate. We may use BCBSMA prescription claims to verify trials; if claims do not confirm trials, the provider must submit chart notes or other supporting clinical documentation. Individual consideration (exception requests) may be submitted with supporting clinical evidence when the criteria are unlikely to be effective for an atypical patient.

    • Evidence of prior use of at least two preferred alternatives required (or clinical rationale for not using them)
    • BCBSMA paid claims may be used to establish prior use; otherwise submit chart notes or prescription history
    • Individual consideration requests should include supporting clinical notes, names/strengths of alternatives tried, relevant labs, literature or guideline references
    Keratoconjunctivitis sicca (Dry Eye Syndrome) is a disorder of the tear film and ocular surface in which inflammation plays a key role.
    Guideline reference (AAO)Referenced: American Academy of Ophthalmology Preferred Practice Pattern Guidelines: Dry Eye Syndrome (2011 limited revision; 2013).
    Clinical literaturePolicy cites literature on inflammation and anti-inflammation therapies in keratoconjunctivitis sicca (Gumas et al., Clinical Ophthalmology 2009).

    Lacrisert (hydroxypropyl cellulose) added to the policy.

    2023-03policy_update

    Vevye (cyclosporine) added to the policy as non-covered.

    2023-10policy_update

    Miebo (perfluorohexyloctane) added to the policy and policy reformatted.

    2023-09policy_update

    Clarified FE criteria when using cyclosporine and updated IC section to align with 118E MGL § 51A.

    2023-07policy_update

    Policy reformatted.

    2023-06policy_update

    Updated criteria for cyclosporine, Xiidra, and Eysuvis and added authorization lengths for drug groupings.

    2022-07policy_update

    Verkazia included in the policy.

    2022-04policy_update

    Generic Restasis added and Restasis moved to non-preferred status.

    2022-02policy_update

    Tyrvaya nasal spray added to the policy.

    2021-04policy_update

    Clarified age for Xiidra.

    2021-01policy_update

    Eysuvis added to the policy.

    2020-01policy_update

    Criteria for Restasis Multidose updated to not covered.

    2019-10policy_update

    Clarified Cequa coverage.

    2019-02policy_update

    Cequa added to the policy.

    2017-06administrative_update

    Updated address for Pharmacy Operations.

    2016-11policy_update

    Xiidra added to the policy.