Blue Cross MA topical ocular agents Prior Auth

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

Eysuvis	loteprednol etabonate
Xiidra	lifitegrast
Miebo	perfluorohexyloctane
Verkazia	cyclosporine
Cyclosporine single use vials	cyclosporine (single use)
Lacrisert	hydroxypropyl cellulose
Restasis single use vials	cyclosporine single use
Restasis multidose	cyclosporine multidose
Cequa	cyclosporine
Tryptyr	acoltremon

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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)

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

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

Lacrisert (hydroxypropyl cellulose) added to the policy.

OpenPayer

Topical ocular hydrating agents and related ophthalmic medications prior authorization

Coverage and Medical Necessity Criteria

Formulary Listings, Codes, and Age/Approval Details

Prior Authorization, Documentation, and Submission Instructions

Background and Scope

Diagnostic and Term Definitions

Policy Revision History