Lacrisert (hydroxypropyl cellulose ophthalmic insert)
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.
Annual revision completed with no criteria changes.
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).
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