CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Cyclosporine ophthalmic emulsion 0.05%

Defines coverage criteria, step therapy logic, required documentation, coverage duration, and investigational exclusion for cyclosporine ophthalmic emulsion 0.05% for members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCyclosporine ophthalmic emulsion 0.05%

Policy CodePolicy N/A

Change TypeClarified

Effective DateFeb 1, 2020

Next Review Date

Key ActionSubmit documentation showing the member trialed and had an inadequate response or intolerance to formulary artificial tears; claims history within the last 365 days will be used to verify prior trial.

SourceLink

POLICY UPDATE CHANGES

Coverage requires trial and inadequate response or intolerance to formulary artificial tears.

12 monthsCoverage Duration

365Lookback (days)

Coverage Summary

Coverage stance: covered_with_criteria for Cyclosporine ophthalmic emulsion 0.05%. Scope: Defines coverage criteria, step therapy logic, required documentation, coverage duration, and investigational exclusion for cyclosporine ophthalmic emulsion 0.05% for members of Neighborhood Health Plan of Rhode Island. Coverage duration: 12 months.

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Step Therapy & Provider Actions

Step Therapy / Coding Logic

Step logic for payment determination:

Payment allowed if ANY of the following

There is at least one claim within the last 365 days for formulary artificial tears.>= 1 claim within last 365 days
There is an existing paid claim for cyclosporine ophthalmic emulsion 0.05% (paid days).paid days on record

Documentation Required

Document trial of artificial tears

Submit documentation showing the member trialed and had an inadequate response or intolerance to formulary artificial tears; claims history within the last 365 days will be used to verify prior trial.

Lookback: 365 days

Step Therapy

Step therapy payment logic

Payment will be allowed if there is at least one claim in the prior 365 days for formulary artificial tears or if cyclosporine ophthalmic emulsion 0.05% has paid days on record.

At least one claim for formulary artificial tears within the last 365 days
Existing paid cyclosporine ophthalmic emulsion 0.05% paid days on record

Investigational Uses & Exclusions

Investigational use: Neighborhood does not provide coverage for drugs when used for investigational purposes. Investigational use is defined as therapies used at a dose or for a condition other than recognized medically accepted indications as defined in AHFS‑DI, Thomson Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi‑Drugs, or peer‑reviewed published medical literature. Investigational uses and non‑compendium dosing/indications are excluded.

Background

Cyclosporine ophthalmic emulsion 0.05% is covered when members have trialed and experienced an inadequate treatment response or intolerance to formulary artificial tears. The policy requires documentation of the trial and will verify prior use via claims history within the last 365 days; payment is allowed if there is at least one claim for formulary artificial tears in that lookback period or if cyclosporine paid days exist.

Lookback for prior trial>= 1 claim within last 365 days for formulary artificial tears

Coverage Duration12 months

dates.effective02/01/2020

dates.last_review07/2025

Revision History

2020-02-01policy_effective

Policy effective date for coverage of cyclosporine ophthalmic emulsion 0.05%.

2025-07policy_reviewedLatest

Policy last reviewed in 07/2025.

coverage_change

Coverage requires trial and inadequate response or intolerance to formulary artificial tears; step logic specifies a 365-day lookback for prior claims of formulary artificial tears or existing paid cyclosporine claims.