CurrentCignaPolicy N/A

Ophthalmology - Upneeq Prior Authorization Policy

Defines Cigna's coverage stance and prior authorization expectations for Upneeq for treatment of acquired blepharoptosis and other uses; applies to Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyOphthalmology - Upneeq Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateOct 22, 2025

Key ActionDo not approve Upneeq requests—coverage is considered experimental/investigational due to insufficient evidence of clinically meaningful benefit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not recommendedcoverage stance for Upneeq

n=304trial population

6 weeksprimary study duration

No long-term dataevidence gap

Coverage Criteria for Upneeq (oxymetazoline 0.1%)

Conditions considered not covered

Upneeq is considered experimental, investigational, or unproven and is not recommended for approval for the following:

Blepharoptosis: Upneeq for acquired blepharoptosis is not recommended for approval due to insufficient clinical efficacy data; Phase 3 randomized, double-masked, placebo-controlled trials (pooled n=304) showed statistically significant but small differences in Leicester Peripheral Field Test (LPFT) and marginal reflex distance 1 (MRD1) versus vehicle with unclear clinical meaningfulness, and primary/secondary endpoints were assessed only through Days 1 and 14 with study duration up to 42 days (6 weeks).

Onset of action was rapid and sustained through Day 42 in pooled analysis; no long-term efficacy data; role in management of blepharoptosis is not established.

Conjunctivitis: Oxymetazoline 0.1% ophthalmic solution has not been evaluated for conjunctivitis; use for this condition is considered unproven.

Cosmetic uses: Use of Upneeq for cosmetic purposes (blepharoptosis without functional limitation) is excluded from coverage under a typical pharmacy benefit and is not recommended.

Policy Summary

PayerCigna

PolicyOphthalmology - Upneeq Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateOct 22, 2025

Key ActionDo not approve Upneeq requests—coverage is considered experimental/investigational due to insufficient evidence of clinically meaningful benefit.

SourceLink

On This Page

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Provider Actions, Prior Authorization, and Denial Guidance

Prior Authorization

Prior authorization not recommended

Prior authorization for Upneeq is not recommended because the medication is considered experimental, investigational, or unproven due to insufficient evidence of clinically meaningful benefit.

Step Therapy

Step therapy not specified

No step therapy pathways or requirements are specified in this policy; the document notes a lack of comparative studies versus surgical or other treatments for blepharoptosis.

Documentation Required

Documentation and review expectations

When evaluating coverage requests, reviewers should consult the applicable benefit plan document, any applicable laws or regulations, relevant collateral materials, and the specific facts of the case; medical directors retain discretion in individual determinations.

Denial Risk

Denial risk for Upneeq

Requests for Upneeq are not recommended for approval and are at high risk for denial because current clinical efficacy data are insufficient and the medication is considered experimental/investigational.

Note

Cosmetic use exclusion

Coverage for cosmetic uses—defined as blepharoptosis when functional limitation is absent—is excluded from coverage in a typical pharmacy benefit and will be denied.

Definitions

Blepharoptosis (ptosis) — definition and common causes

DefinitionAbnormal drooping of one or both upper eyelids (blepharoptosis or ptosis).

Common formsCan be congenital or acquired; acquired forms are most commonly aponeurotic (involutional).

Typical cause of aponeurotic ptosisStretching, dehiscence, or disinsertion of the levator aponeurosis.

Other causesMyogenic (e.g., myasthenia gravis), neurogenic (e.g., third nerve palsy), traumatic (eyelid laceration), or mechanical (mass or scarring).

Clinical impact and managementCan impair visual field and cause psychosocial effects; surgical interventions are the primary management and may require repeat procedures due to recurrence.

Surgical risksPotential complications include bleeding, infection, under‑ or overcorrection, eyelid asymmetry, granuloma, corneal foreign‑body sensation, and exposure keratopathy.

Upneeq — drug definition

Generic name and formulationOxymetazoline hydrochloride 0.1% ophthalmic solution.

Brand nameUpneeq (RVL Pharmaceuticals).

Mechanism classAlpha‑adrenergic agonist (topical ophthalmic agent).

IndicationIndicated for the treatment of acquired blepharoptosis in adults.

Evidence summary noteClinical benefit versus existing treatments is uncertain; short‑term trial data only and insufficient to establish long‑term effectiveness.

OpenPayer

Ophthalmology - Upneeq Prior Authorization Policy

Coverage Criteria for Upneeq (oxymetazoline 0.1%)

Provider Actions, Prior Authorization, and Denial Guidance

Background

Definitions