Currentmedical mutual - ohioPolicy N/A

Eysuvis (loteprednol etabonate ophthalmic suspension) coverage criteria

Defines prior authorization and coverage criteria for Eysuvis for short-term treatment of signs and symptoms of dry eye disease for adults, and describes documentation and approval durations relevant to Medical Mutual - Ohio pharmacy benefit coverage.

Policy Summary

Payermedical mutual - ohio

PolicyEysuvis (loteprednol etabonate ophthalmic suspension) coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateApr 17, 2025

Key ActionObtain prior authorization and ensure prescription is by or in consultation with a specialist and that patient tried preservative-free artificial tears.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Up to 2 weeksFDA-indicated duration of therapy

18+Minimum patient age for coverage

1 moInitial approval duration

1 moExtended approval duration

Objective test requiredHomeostasis marker

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.

Coverage Criteria for Eysuvis

Dry Eye Disease

Covered when ALL of the following are met for Dry Eye Disease:

ALL of the following

Patient is 18 years of age or older.
Eysuvis is prescribed by or in consultation with an ophthalmologist, optometrist, or rheumatologist.
Prescriber-administered homeostasis testing
- Schirmer's test with < 5 mm of wetting over 5 minutes.
- Non-invasive tear breakup time (TBUT) result of 10 seconds or less.
- Osmolarity result of >= 308 mOsm/L in either eye OR an interocular difference > 8 mOsm/L.
- Ocular surface staining with > 5 corneal spots OR > 9 conjunctival spots, OR lid margin involvement (>= 2 mm length and >= 25% width).
The patient has tried preservative-free artificial tears.

Dry Eye Disease, Continuation of Therapy

Covered when ALL of the following are met for Continuation of Therapy:

ALL of the following

Patient is 18 years of age or older.
The medication is prescribed by or in consultation with an ophthalmologist, optometrist, or rheumatologist.
The patient has had a beneficial response to therapy, including reduced eye irritation, dryness, red eyes, or burning.

Objective Test Thresholds and Coding Related Values

Schirmer's test wetting — criteria

ThresholdSchirmer's test wetting < 5 mm over 5 minutes

Test descriptionMeasures tear production by quantifying wetting of filter paper over 5 minutes

Use in policyOne required homeostasis marker for initial coverage of dry eye disease with Eysuvis

Non‑invasive tear breakup time (TBUT) — criteria

ThresholdNon‑invasive tear breakup time (TBUT) ≤ 10 seconds

Test descriptionAssesses tear film stability by measuring time to first dry spot after blinking

Use in policy

Prescriber and Prior Authorization Requirements

Prior Authorization

Prior Authorization and Specialist Prescriber

Prior authorization is recommended for pharmacy benefit coverage. Initial approval requires the drug be prescribed by or in consultation with a physician who specializes in the condition being treated (ophthalmologist, optometrist, or rheumatologist).

Prescriber or consultation must be a specialist (ophthalmologist, optometrist, or rheumatologist).

Note

Approval Durations

Initial approval duration: 1 month. Extended approval duration: 1 month.

Initial Approval: 1 month
Extended Approval: 1 month

Clinical Background

Eysuvis (loteprednol etabonate ophthalmic suspension) is a topical corticosteroid indicated for short‑term treatment — up to two weeks — of the signs and symptoms of dry eye disease. This policy defines prior authorization and coverage criteria for Eysuvis under the pharmacy benefit, including patient eligibility (adult patients ≥ 18 years), requirement for specialist prescriber involvement, objective testing demonstrating tear film or ocular surface abnormality, and a prior trial of preservative‑free artificial tears. Initial and extended approvals are time‑limited and require documentation of clinical benefit for continuation.

Drug Definition

Eysuvis — definition and FDA indication

DrugEysuvis (loteprednol etabonate ophthalmic suspension)

FDA indicationShort‑term treatment (up to two weeks) of the signs and symptoms of dry eye disease

FormulationOphthalmic suspension (topical corticosteroid)

Policy Summary

Payermedical mutual - ohio

PolicyEysuvis (loteprednol etabonate ophthalmic suspension) coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateApr 17, 2025

Key ActionObtain prior authorization and ensure prescription is by or in consultation with a specialist and that patient tried preservative-free artificial tears.

SourceLink

On This Page

One acceptable homeostasis marker to meet initial coverage criteria for Eysuvis

Osmolarity — criteria

ThresholdOsmolarity ≥ 308 mOsm/L in either eye OR interocular difference > 8 mOsm/L

Test descriptionTear osmolarity measurement indicating hyperosmolarity consistent with dry eye disease

Use in policyOne acceptable homeostasis marker to meet initial coverage criteria for Eysuvis

Ocular surface staining — criteria

ThresholdOcular surface staining > 5 corneal spots OR > 9 conjunctival spots OR lid margin ≥ 2 mm length and ≥ 25% width

Test descriptionFluorescein/lissamine staining assessment of corneal, conjunctival, or lid margin damage

Use in policyOne acceptable homeostasis marker to meet initial coverage criteria for Eysuvis

Required Prior Therapy

Patient must have tried preservative-free artificial tears prior to approval.

Required prior therapy: preservative-free artificial tears

Documentation Required

Documentation Required on Request

The Company may request additional documentation to support coverage determinations. Be prepared to provide patient records, relevant test results (e.g., Schirmer's test, TBUT, osmolarity, ocular surface staining), and prescriber credentials. Additional documentation may be requested to support medical necessity.

Acceptable test results include: Schirmer's test (<5 mm/5 min); TBUT ≤10 seconds; Osmolarity ≥308 mOsm/L or interocular difference >8 mOsm/L; Ocular surface staining >5 corneal spots or >9 conjunctival spots, or lid margin ≥2 mm length and ≥25% width.
Prescriber credentials and documentation of specialist consultation when applicable.
Patient records showing trial of preservative-free artificial tears.

Denial Risk

Denial Triggers

Claims may be denied if the drug or services were not medically necessary, were investigational/experimental, were outside the member's benefits, or if required documentation is missing. The Company may also deny reimbursement for inappropriate or excessive billing patterns.

Denial triggers: lack of medical necessity, investigational/experimental use, not within scope of benefits, missing required documentation, inappropriate or excessive billing patterns.