CurrentCignaPolicy N/A

Eysuvis (loteprednol 0.25%) prior authorization for dry eye disease

This policy governs prior authorization and coverage criteria for Eysuvis (loteprednol etabonate 0.25% ophthalmic suspension) for treatment of dry eye disease under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyEysuvis (loteprednol 0.25%) prior authorization for dry eye disease

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document a trial of artificial tears; approvals for the FDA‑approved short-term indication are authorized for 1 month.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 monthinitial approval duration

up to 2 weeksFDA indicated duration

IOP/cataract riskmonitoring

Not medically necessarynon-covered uses

Coverage Criteria for Eysuvis (loteprednol 0.25%)

Initial therapy — FDA-approved indication

Policy Summary

PayerCigna

PolicyEysuvis (loteprednol 0.25%) prior authorization for dry eye disease

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document a trial of artificial tears; approvals for the FDA‑approved short-term indication are authorized for 1 month.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Recommended

Prior authorization recommended for prescription benefit coverage of Eysuvis. Approvals are provided for the duration noted in the policy; when expressed in months, 1 month = 30 days.

Eysuvis (loteprednol etabonate 0.25% ophthalmic suspension)
Prior authorization recommended; submit requests per plan

Step Therapy

Required Trial Prior to Approval

Patient must have tried artificial tears prior to approval for short-term use (Dry Eye Disease). Approve for 1 month when criterion met.

Indication: Dry Eye Disease (including dry eye syndrome, keratoconjunctivitis sicca)
Required trial: artificial tears prior to approval

Documentation Required

Billing and Plan‑Document Requirements

Submit prior authorization and coverage requests in accordance with the applicable benefit plan document. Include supporting clinical information such as diagnosis, prior therapy (e.g., trial of artificial tears), treatment duration requested, and any relevant clinical notes or test results to facilitate review.

Follow the member's specific benefit plan requirements
Include clinical documentation supporting FDA‑approved indication and prior-treatment history

Denial Risk

Non‑Covered Uses

Requests for Eysuvis for any use other than the specified short‑term treatment of dry eye disease are considered not medically necessary and will be denied; criteria will be updated as new published data become available.

Non‑covered: Any indication other than short‑term Dry Eye Disease treatment

Background

Dry eye disease (also called dry eye syndrome or keratoconjunctivitis sicca) is characterized by ocular surface discomfort and signs of tear film instability. Management typically follows a staged approach; initial measures include artificial tears and other nonpharmacologic therapies. Ophthalmic corticosteroids such as Eysuvis may be used short-term to reduce ocular surface inflammation and relieve symptoms, but use beyond the approved short-term indication is not covered under this policy.

Definitions

Dry eye disease — definitions and management

Also known asDry eye disease is also called dry eye syndrome or keratoconjunctivitis sicca.

ClassificationGenerally classified by symptoms and signs (mild, moderate, severe) with emphasis on symptoms over signs.

Management approachManaged using a staged, stepwise approach to therapy; specific therapies may be chosen from any step based on provider judgement and patient preference.

Role of ophthalmic corticosteroidsLow‑dose ophthalmic corticosteroids (including loteprednol formulations) can reduce ocular irritation symptoms and may be used short‑term to suppress ocular surface inflammation.

Monitoring requirementsPatients using ophthalmic corticosteroids should be monitored for increased intraocular pressure and cataract formation.

Eysuvis (loteprednol etabonate 0.25%)

Active ingredient & strengthLoteprednol etabonate 0.25% ophthalmic suspension.

FDA‑approved indicationIndicated for short‑term treatment of the signs and symptoms of dry eye disease (examples include dry eye syndrome and keratoconjunctivitis sicca).

Duration of indicated use (overview)Short‑term: up to 2 weeks per the product overview.

Coverage/prior authorization guidanceApprovals for the FDA‑approved indication are authorized for 1 month if the patient has tried artificial tears.

Non‑covered usesAny use other than short‑term treatment of dry eye disease is considered not medically necessary per the policy.

OpenPayer

Eysuvis (loteprednol 0.25%) prior authorization for dry eye disease

Coverage Criteria for Eysuvis (loteprednol 0.25%)

Coding Guidance

Provider Actions and Authorization Requirements

Background

Definitions