PRIOR AUTHORIZATION POLICY
This policy defines prior authorization and medical necessity criteria for coverage of Lacrisert (hydroxypropyl cellulose ophthalmic insert) for treatment of moderate to severe dry eye and related ocular conditions for Cigna-administered health benefit plans. It specifies covered FDA‑approved indications, duration of approvals, and that other uses are not medically necessary.
Annual revisions conducted with no criteria changes noted (review dates 12/06/2023 and 12/11/2024).
Coverage Summary
Scope: This policy defines prior authorization and medical necessity criteria for coverage of Lacrisert (hydroxypropyl cellulose ophthalmic insert) for treatment of moderate to severe dry eye and related ocular conditions for Cigna‑administered health benefit plans. Coverage stance: Covered with criteria — Lacrisert is covered when criteria are met (FDA‑approved indications and documentation of a trial of artificial tears). Covered indications: Lacrisert is approved for ocular conditions associated with moderate to severe dry eye (including but not limited to decreased corneal sensitivity, dry eye syndrome/keratoconjunctivitis sicca, exposure keratitis, and recurrent corneal erosions). Approval duration: 1 year. Other uses: Use of Lacrisert for any indication other than the specified ocular conditions associated with moderate to severe dry eye is considered not medically necessary.