CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Cyclosporine ophthalmic emulsion 0.05% — Coverage Criteria

Defines coverage and prior‑authorization requirements for cyclosporine ophthalmic emulsion 0.05% for members, including step‑therapy with formulary artificial tears and coverage duration.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCyclosporine ophthalmic emulsion 0.05% — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2020

Next Review DateN/A

Key ActionObtain documentation showing trial and inadequate response or intolerance to formulary artificial tears (one paid claim in prior 365 days) to support prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthscoverage duration per approval

365 dayslook‑back period for step therapy claim

0.05%drug concentration covered

1trial of formulary artificial tears required

Coverage Criteria

Medical necessity and step‑therapy criteria

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCyclosporine ophthalmic emulsion 0.05% — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2020

Next Review DateN/A

Key ActionObtain documentation showing trial and inadequate response or intolerance to formulary artificial tears (one paid claim in prior 365 days) to support prior authorization.

SourceLink

On This Page

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Initial coverage criteria: The member has trialed and experienced an inadequate treatment response or intolerance to formulary artificial tearstrial documented

Documentation must show trial and inadequate response or intolerance

Step therapy claim requirement: At least one paid claim within the last 365 days for formulary artificial tears or cyclosporine ophthalmic emulsion 0.05%>=1 paid claim in 365 days

Used for step-therapy verification

Coverage duration: If approved, coverage duration is 12 months12 months

Renewal criteria not specified in document

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests must document a trial and inadequate response or intolerance to formulary artificial tears. If approved, coverage duration is 12 months.

Affected drug: Cyclosporine ophthalmic emulsion 0.05%
Coverage duration: 12 months
Reference look‑back: 365 days for formulary artificial tears

Step Therapy

Step Therapy Requirement

Step therapy requirement: approval is granted only if there is at least one paid claim within the last 365 days for formulary artificial tears or for cyclosporine ophthalmic emulsion 0.05%.

Look‑back period: 365 days
Acceptable evidence: paid pharmacy claim for formulary artificial tears or cyclosporine 0.05%

Documentation Required

Required Clinical Documentation

Document clinical rationale showing the member trialed and had an inadequate response or intolerance to formulary artificial tears. Include dates, products used, and reason for discontinuation or failure.

Required documentation: trial dates, product names, clinical outcome or intolerance details
Evidence type: medical record notes or pharmacy claims

Denial Risk

Failure to Meet Step‑Therapy Trial — Denial Risk

Failure to meet the step‑therapy trial or lack of documentation within the 365‑day look‑back will result in denial or noncoverage of the request.

Denial trigger: no paid claim for formulary artificial tears within prior 365 days or missing documentation of trial/intolerance

Background

Cyclosporine ophthalmic emulsion 0.05% is an ophthalmic anti‑inflammatory agent used to increase tear production in patients whose tear production is presumed suppressed due to ocular surface inflammation (commonly used for dry eye disease). Prior authorization requires documentation that the member has trialed and experienced an inadequate treatment response or intolerance to formulary artificial tears. For step‑therapy verification, the policy uses a 365‑day look‑back for at least one paid claim for formulary artificial tears or for cyclosporine 0.05%. If approved, the coverage duration is up to 12 months.

Definitions

inv-10: 365‑day look‑back definition used for step therapy claims

DefinitionA 365‑day period used by step‑therapy coding logic to determine whether there is at least one paid claim for formulary artificial tears or cyclosporine ophthalmic emulsion 0.05%

Used forVerifying trial of formulary artificial tears or prior cyclosporine 0.05% before approving cyclosporine 0.05%

Evidence requiredDocumented paid claim within the last 365 days

inv-11: Coverage duration — maximum authorized period for a single approval is 12 months

Maximum single approval period12 months

Policy statementIf approved, coverage duration is 12 months

Renewal noteRenewal criteria are not specified in the source document

OpenPayer

Cyclosporine ophthalmic emulsion 0.05% — Coverage Criteria

Coverage Criteria

Coding

Provider Actions & Prior Authorization

Background

Definitions