CurrentCignaPolicy N/A

Lacrisert (hydroxypropyl cellulose ophthalmic insert)

Policy Summary

PayerCigna

PolicyLacrisert (hydroxypropyl cellulose ophthalmic insert)

Policy CodePolicy N/A

Change TypeAnnual revision — no criteria changes

Effective Date

Next Review Date

Key ActionPrior authorization is required and approvals are provided for 1 year when criteria are met; document a trial of artificial tears prior to approval.

POLICY UPDATE CHANGES

Annual revision completed with no criteria changes.

1Required Prior Therapy (artificial tears)

1Approval Duration (years)

Coverage Summary

Cigna prior authorization policy for coverage of Lacrisert ophthalmic inserts for moderate to severe dry eye and related ocular conditions; defines approval criteria, duration, and exclusions for other uses. This policy requires prior authorization for Lacrisert and outlines that approvals are provided for a duration of 1 year when criteria are met.

Coverage stance: covered_with_criteria — Lacrisert is covered when specified criteria are met (FDA-approved indication for ocular conditions associated with moderate to severe dry eye and documentation of prior trial of artificial tears).

Medically Necessary Coverage (FDA-Approved Indication)

Lacrisert is covered as medically necessary when ALL of the following are met:

ALL of the following

Indication: Ocular conditions associated with moderate to severe dry eye (e.g., decreased corneal sensitivity, dry eye syndrome, exposure keratitis, keratoconjunctivitis sicca, recurrent corneal erosions)
Patient has tried artificial tears
Approval granted for 1 year if criteria met

FDA-Approved Indication: Ocular Conditions Associated with Moderate to Severe Dry Eye. Approve for 1 year if the patient has tried artificial tears.

Not Covered / Experimental or Unproven Uses

Lacrisert is considered experimental, investigational or unproven for ANY other use(s) including the following; criteria will be updated as new published data are available:

Any use not listed in the FDA-approved indication section or not supported by evidence cited in the policy

Provider Actions

Prior Authorization

Prior Authorization Required

Prior authorization is recommended/required for prescription benefit coverage of Lacrisert; approvals are provided for a duration of 1 year when criteria are met.

Approvals are provided for 1 year when criteria are met

Documentation Required

Document prior therapy

Provider must document trial of artificial tears prior to approval; Lacrisert is indicated especially in patients who remain symptomatic after an adequate trial of therapy with artificial tear solutions.

Quick Thresholds / Operational Values

Required Prior Therapy (artificial tears)1

Approval Duration1 year

Clinical Evidence & References

Evidence sources cited in this policy include the FDA Prescribing Information for Lacrisert (Bausch & Lomb; October 2019) and the American Academy of Ophthalmology (AAO) Dry Eye Syndrome Preferred Practice Pattern, 2024.

The FDA prescribing information provides the product indication and supporting clinical context for Lacrisert as a slow‑release hydroxypropyl cellulose ophthalmic insert indicated for moderate to severe dry eye syndromes and related conditions.

The AAO guideline notes that artificial tears are a safe and effective modality for dry eye and that slow‑release hydroxypropyl cellulose inserts may be helpful for patients unable to apply artificial tears, supporting the coverage requirement that Lacrisert is used when patients remain symptomatic after a trial of artificial tears.

Background & Definitions

Lacrisert is a slow‑release hydroxypropyl cellulose ophthalmic insert indicated for moderate to severe dry eye syndromes (including keratoconjunctivitis sicca) and related ocular conditions such as exposure keratitis, decreased corneal sensitivity, and recurrent corneal erosions. It is indicated especially for patients who remain symptomatic after an adequate trial of artificial tear therapy.

Definition: Lacrisert — Hydroxypropyl cellulose ophthalmic insert (Bausch & Lomb) used for moderate to severe dry eye and related ocular conditions.