Clinical Policy: Lifitegrast (Xiidra)
Defines medical necessity criteria, prior authorization expectations, dosing/quantity limits, and continuation criteria for lifitegrast (Xiidra) for treatment of signs and symptoms of dry eye disease for commercial, HIM, and Medicaid lines of business.
Added requirement for topical anti-inflammatory agents and reduced number of wetting agents required from 2 to 1 (removed duration of trial).
Clarified that redirection to alternative agents are required unless clinically significant adverse effects or contraindications exist.
Appendix B consolidated therapeutic alternatives and added asterisks noting prior authorization may be required for certain alternatives.
Clarified off-label uses for ophthalmic anti-inflammatory agents and added Appendix D guideline info.