CurrentColorado Rocky Mountain Health PlansPolicy N/A

Ophthalmic Immunomodulators (Xiidra) - Washington Prior Authorization

Prior authorization form and requirements for Xiidra (ophthalmic immunomodulator) for treatment of moderate to severe chronic dry eye disease; governs providers requesting approval for members covered by the plan.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOphthalmic Immunomodulators (Xiidra) - Washington Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with diagnosis, diagnostic test results, prior cyclosporine trial details, and supporting documentation; allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursreview time

28 daysminimum cyclosporine trial

<=10stear break-up time

<=10mmSchirmer test

Coverage Criteria for Xiidra (Ophthalmic Immunomodulators)

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.

Initial Therapy

Covered when ALL of the following are met:

Initial Authorization for Xiidra: 1) Diagnosis of moderate to severe chronic dry eye disease (DED).

Diagnostic evidence: 2) Documentation of an abnormal result or response on one or more of the following assessments: tear break-up time < 10 seconds; ocular surface dye staining (fluorescein, rose bengal, or lissamine green); Schirmer test ≤ 10 mm strip wetting in 5 minutes; fluorescein clearance test/tear function index; abnormal tear osmolarity; decreased tear lactoferrin concentration.

Prior cyclosporine trial when applicable: 3) History of failure, contraindication, or clinically significant intolerance to cyclosporine 0.05% ophthalmic emulsion (Restasis) for at least 28 days when applicable (if yes, complete Section D documenting previous medication trials and reason for failure).>= 28 days when applicable

Document prior trials in Section D

Prescriber qualification: 4) Medication is prescribed by or in consultation with a specialist in eye care or rheumatology.

Dosage limit: 5) Dose does not exceed 2 drops per day in each eye.<= 2 drops/day per eye

Use exceeding 2 drops per day in each eye is queried; dose exceeding this may not meet requirements.

Continuation Therapy

Covered when ALL of the following are met:

Continuation of Therapy: 1) Request is for continuation of therapy (document current therapy and start date).

If continuation, list start date on the form.

Clinical response: 2) Documentation of clinically significant improvement (provider to list improvement details).clinical improvement documented

Provider attestation: 3) Provider signature and date on the request form.

Requests will be queried if the dose exceeds 2 drops per day in each eye. Dosing above this threshold may not meet the coverage requirements and should be avoided unless clearly justified in the submitted documentation.

Requests that do not include documentation of an abnormal diagnostic/assessment result (for example, tear break-up time <10 seconds, positive ocular surface dye staining, or Schirmer ≤10 mm/5 min) or that lack a documented history of failure, contraindication, or intolerance to cyclosporine 0.05% ophthalmic emulsion (Restasis) when applicable may be considered not medically necessary and can be denied.

Diagnosis and Test Codes / Thresholds

Diagnosis codes (form field)ICD-10

ICD-10 CODE

Place to record the member's ICD-10 diagnosis code on the form

Tear break-up time — clinical threshold cited

Tear break-up time (TBUT)Less than 10 seconds is cited as abnormal and supports diagnosis of moderate to severe chronic dry eye disease.

Supporting assessmentsTBUT is listed among other acceptable diagnostic/assessment methods (ocular surface staining, Schirmer, fluorescein clearance, tear osmolarity, tear lactoferrin).

Use in prior authorizationDocumentation of an abnormal TBUT (<10s) must be provided on the prior authorization form to meet diagnostic criteria.

Schirmer test — clinical threshold cited (<= 10 mm in 5 min)

Schirmer test thresholdAqueous tear production ≤ 10 mm of strip wetting in 5 minutes is cited as abnormal.

Role in diagnosisSchirmer ≤10 mm/5 min is an accepted diagnostic/assessment method to document dry eye disease on the prior authorization form.

Documentation requirementAn abnormal Schirmer result must be included with the request to support medical necessity when applicable.

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required; allow at least 24 hours for review. Requests must document diagnosis, diagnostic testing, and medication history. Complete and fax the Prior Authorization Request Form with all sections filled to avoid delay. Contact the number on the form for questions.

Fax completed form to: 866-940-7328
Call with questions: 800-310-6826
Include member and provider information, medication name/strength/directions, diagnosis and ICD-10 code, and supporting documentation

Documentation Required

Required form completion

Completed prior authorization form including member and provider information, medication details, diagnosis, and supporting documentation (previous medication trials, dates, and reasons for failure) must be submitted. Ensure Section D (Previous Medication Trials) is completed when documenting prior cyclosporine use or other trials.

Include dates of therapy and reason for failure/discontinuation for prior treatments
If continuation of therapy, include start date and documentation of ongoing benefit

Documentation Required

Required trial of cyclosporine (when applicable)

Documented history of failure, contraindication, or intolerance to cyclosporine 0.05% ophthalmic emulsion (Restasis) for at least 28 days is required when applicable. If trialed, complete Section D to show dates and reasons for discontinuation. Note whether the medication is being used concomitantly with cyclosporine and whether the dose exceeds 2 drops per day in each eye.

Document at least 28 days of cyclosporine 0.05% use if claiming failure/intolerance
If cyclosporine was tried, include reason for failure/contraindication/intolerance
Indicate if medication is being used with cyclosporine and confirm dosing limits (≤2 drops/day per eye)

Denial Risk

Insufficient diagnostic documentation

Lack of documentation of a diagnosis of moderate to severe chronic dry eye disease (DED) or absence of documented abnormal diagnostic/assessment testing (e.g., TBUT, Schirmer, ocular surface staining, tear osmolarity) may lead to denial of the request.

Provide documentation for at least one abnormal diagnostic/assessment method (e.g., TBUT <10s, Schirmer ≤10 mm/5 min, ocular surface dye staining, tear osmolarity)
Confirm diagnosis of moderate to severe chronic DED in the medical record

Background and Definitions

This policy governs prior authorization for an ophthalmic immunomodulator used to treat moderate to severe chronic dry eye disease (DED). The form requires documentation of the diagnosis and abnormal findings from one or more accepted diagnostic or assessment methods—such as tear break-up time <10 seconds, ocular surface dye staining, Schirmer test ≤10 mm in 5 minutes, fluorescein clearance/tear function index, tear osmolarity, or decreased tear lactoferrin. For initial approvals, when applicable, the request must also document a history of failure, contraindication, or intolerance to cyclosporine 0.05% ophthalmic emulsion (Restasis) for at least 28 days, and the medication should be prescribed by or in consultation with an eye care specialist or rheumatology.

DED — Definition: Moderate to severe chronic dry eye disease

DefinitionModerate to severe chronic dry eye disease (DED)

Diagnostic supportDiagnosis must be documented and supported by abnormal results from one or more listed assessments (e.g., TBUT <10s, Schirmer ≤10 mm/5 min, ocular surface staining).

Relevance to therapyThe diagnosis of moderate to severe chronic DED is a required element on the prior authorization form for Xiidra therapy.