CurrentCignaPolicy N/A

Ophthalmology - Dry Eye Disease - Eysuvis Prior Authorization Policy

Prior authorization policy for prescription benefit coverage of Eysuvis for treatment of dry eye disease for members of Cigna-administered health benefit plans. Defines FDA-approved indication coverage, approval duration, and non-covered uses.

Policy Summary

PayerCigna

PolicyOphthalmology - Dry Eye Disease - Eysuvis Prior Authorization Policy

Policy CodePolicy N/A

Change TypeClarified (annual revision; no criteria changes)

Effective Date

Next Review Date

Key ActionPrior authorization is required; document a trial of artificial tears and note approvals are provided for 1 month (30 days).

POLICY UPDATE CHANGES

Annual revision completed with no criteria changes as of 12/11/2024.

1Covered Indications

1 monthInitial Approval Duration

All other usesNot Covered / Experimental

Coverage Summary

Prior authorization policy for prescription benefit coverage of Eysuvis for treatment of dry eye disease for members of Cigna-administered health benefit plans. Coverage stance: covered_with_criteria.

Eysuvis (loteprednol etabonate 0.25% ophthalmic suspension) is FDA-indicated for short-term (up to 2 weeks) treatment of the signs and symptoms of dry eye disease; the policy approves therapy for 1 month (30 days) when criteria are met.

Medically Necessary (FDA-Approved Indication)

Covered when ALL of the following are met:

ALL of the following

Indication is Dry Eye Disease (short-term treatment)
Patient has tried artificial tears

Provider Actions & Requirements

Prior Authorization

Prior authorization required

Prior authorization is recommended/required for prescription benefit coverage of Eysuvis; approvals provided for specified duration (1 month = 30 days).

Approval duration: 1 month (30 days)

Documentation Required

Document trial of artificial tears

Provider must document that the patient has tried artificial tears prior to approval.

Denial Risk

Denial for non-FDA uses

Claims for any use other than short-term treatment of dry eye disease may be considered experimental/investigational and denied.

Clinical Evidence & References

Evidence includes: FDA Prescribing Information: Eysuvis ophthalmic suspension; Alcon; November 2023 and the AAO Dry Eye Syndrome Preferred Practice Pattern, Ophthalmology 2024;131(4):P1-P49.

Clinical monitoring is recommended for adverse effects of ophthalmic corticosteroids, specifically increased intraocular pressure and cataract formation.

Background & Definitions

Eysuvis is an ophthalmic corticosteroid indicated for the short-term (up to 2 weeks) treatment of the signs and symptoms of dry eye disease.

Ophthalmic corticosteroids can reduce ocular irritation symptoms; patients should be monitored for adverse effects such as increased intraocular pressure and cataract formation.

Definitions

TermShort-term

DefinitionPolicy references FDA indication as short-term (up to 2 weeks) treatment; approval duration by policy is 1 month (30 days).

Source statementEysuvis is indicated for short-term (up to 2 weeks) treatment of signs and symptoms of dry eye disease; approvals are provided for 1 month (1 month = 30 days).