CurrentHealth NetPolicy CP PMN.260

Clinical Policy: Loteprednol etabonate (Eysuvis)

Defines medical necessity criteria, prior authorization and coverage limits for Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%) for short-term treatment of signs and symptoms of dry eye disease across Commercial, HIM, and Medicaid lines of business.

Policy Summary

PayerHealth Net

PolicyClinical Policy: Loteprednol etabonate (Eysuvis)

Policy CodePolicy CP PMN.260

Change TypeClarified (annual review updates)

Effective Date03.01.21

Next Review Date

Key ActionProvider must submit office chart notes, lab results or other clinical information showing member meets all approval criteria.

SourceLink

POLICY UPDATE CHANGES

Authorization may be required for anti-inflammatory agents and Appendix B updated with examples of ophthalmic anti-inflammatory agents.

Appendix B OTC artificial tears examples clarified as non-inclusive list.

14 daysApproval duration

≥ 18Minimum age (years)

1 bottle/14 daysMaximum supply

0.25%Concentration available

Coverage Summary

Defines medical necessity criteria, prior authorization requirements, and coverage limits for Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%) for the short-term treatment of signs and symptoms of dry eye disease across Commercial, HIM, and Medicaid lines of business. Medical necessity requires a diagnosis of dry eye disease, age ≥ 18 years, failure of an artificial tears agent at up to maximally indicated doses and failure of at least one other ophthalmic anti-inflammatory at up to maximally indicated doses (unless contraindicated or not tolerated). Prior authorization documentation is required and requests must not exceed 1 bottle per 14 days; standard approval duration is 14 days with dosing per policy (1–2 drops QID; maximum 8 drops/day in each eye).

Thresholds

Maximum supply≤ 1 bottle per 14 days

Approval duration14 days

Age≥ 18 years

Dosage regimen1-2 drops in each eye QID for up to two weeks; maximum 8 drops/day in each eye

Initial Therapy Criteria

Initial Approval Criteria

Covered when ALL of the following are met: Provider must submit documentation (such as office chart notes, lab results, or other clinical information) supporting that member has met all approval criteria.

ALL of the following

Diagnosis of dry eye disease.
Dry Eye Disease (must meet all)
- Age >= 18 years.
- Failure of an artificial tears agent (see Appendix B for examples) at up to maximally indicated doses, unless clinically significant adverse effects are experienced or all are contraindicated.
- Failure of at least one other ophthalmic anti-inflammatory (see Appendix B for examples) at up to maximally indicated doses, unless clinically significant adverse effects are experienced or all are contraindicated.
- Request does not exceed 1 bottle per 14 days.
  Approval duration: 14 days
Prior authorization may be required for ophthalmic anti-inflammatory agents (see formulary/PA policies as applicable).

Other Indications and Not Authorized Uses

Other Diagnoses/Indications

Member must meet one of the following AND additional conditions for continued coverage:

ref': 'b2_0'

title': 'Continuation (Continued) Therapy'

intro': '

nodes': [] } , {

Provider Actions & Billing Rules

Documentation Required

Submit supporting documentation

Provider must submit office chart notes, lab results or other clinical information supporting that the member has met all approval criteria.

Prior Authorization

Prior authorization may be required

Prior authorization may be required for ophthalmic anti-inflammatory agents; follow the applicable prior authorization process and related policies.

Billing Rule

Supply limit enforcement

Requests that exceed 1 bottle per 14 days or that extend beyond the 14-day approval duration risk denial or will require justification.

Background & Clinical Evidence

Eysuvis (loteprednol etabonate) is an ophthalmic corticosteroid indicated for the short-term treatment of the signs and symptoms of dry eye disease. Per AAO guidance, artificial tears are the standard first-line therapy for dry eye, and if tears are inadequate the next step in therapy is ophthalmic anti-inflammatory treatment, which includes topical corticosteroids such as loteprednol. The policy notes typical dosing of 1–2 drops in each eye QID for up to two weeks (maximum 8 drops/day in each eye).

Regulatory / dosing

Evidence summary

Revision History

2025-02-25annual_reviewLatest

1Q 2025 annual review: clarified that authorization may be required for ophthalmic anti-inflammatory agents and Appendix B was updated to add examples of ophthalmic anti-inflammatory agents; references reviewed and updated.

2024-02-24annual_review

1Q 2024 annual review: clarified that Appendix B OTC artificial tears examples are a non-inclusive list; references reviewed and updated.

2021-03-01policy_effective

Policy effective date: 03.01.21; establishes criteria for Eysuvis including requirement to fail artificial tears and at least one ophthalmic anti-inflammatory, approval duration 14 days, and maximum supply ≤ 1 bottle per 14 days.