CurrentPremera BluecrossPolicy N/A

Dry Eye Disease Medications (Pharmacy)

Pharmacy benefit policy describing medical necessity criteria for prescription medications used to treat dry eye disease and related conditions; applies to providers prescribing these drugs and to members under the pharmacy benefit.

Policy Summary

PayerPremera Bluecross

PolicyDry Eye Disease Medications (Pharmacy)

Policy CodePolicy N/A

Change TypeNew policy (moved from 5.01.605)

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization via the pharmacy benefit; approvals may be granted up to 12 months when drug-specific criteria are met.

SourceLink

POLICY UPDATE CHANGES

New policy approved April 14, 2026 and effective May 1, 2026 creating policy 5.01.661 for Dry Eye Disease Medications.

May 1, 2026Effective date

Apr. 14, 2026Last revised

12 monthsMax approval

60Vial limit/30d

YesPharmacy benefit

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.

Drug-specific medical necessity criteria (summary)

Covered when ALL of the following are met (drug-specific criteria summarized below):

General drug coverage node: Member is being treated for the signs and symptoms of dry eye disease

applies to all listed drugs

Age requirement: Member is aged 18 years or older for most drugs (product-specific exceptions noted below)

Verkazia is for vernal keratoconjunctivitis age >=4

Prior trial requirement: Has tried and failed generic cyclosporine ophthalmic emulsion 0.05% unless there is a contraindication to use with cyclosporine ophthalmic; for Eysuvis, has tried and failed two of the listed ophthalmic corticosteroids (dexamethasone, loteprednol etabonate, or fluorometholone)

Applies to cyclosporine agents and specified products; Eysuvis requires two steroid trials

Exclusion for concurrent therapy: Requested product is not being used concurrently with another specified ophthalmic dry eye therapy (examples: other ophthalmic cyclosporine products such as Cequa, Restasis, Vevye; Miebo; Tryptyr; Tyrvaya; Xiidra)

Product-specific concurrent use prohibitions listed in policy

Quantity limit: Prescribed quantity does not exceed product-specific per-30-day limits (examples: 60 single-use vials per 30 days; one 2 mL, 3 mL, or 5.5 mL bottle per 30 days depending on product)

See individual product entries for exact limits

Verkazia (cyclosporine ophthalmic emulsion) - vernal keratoconjunctivitis

Covered when ALL of the following are met for Verkazia:

Verkazia specific: Indicated for vernal keratoconjunctivitis; member is aged 4 years or older; has moderate-to-severe vernal keratoconjunctivitis

Verkazia-specific indication and age requirement as stated in policy

All uses of the drugs listed in this policy that are not specifically described in the coverage criteria are considered investigational and will not be approved. This policy defines the covered indications (for example, treatment of dry eye disease and, for Verkazia, vernal keratoconjunctivitis); any request for these agents for other conditions falls outside the scope of coverage.

Therapy will be considered not medically necessary when the requested drug is used outside the age range specified for that product, when required prior trial(s) have not been completed, when the drug is prescribed concurrently with other prohibited ophthalmic dry eye therapies, or when the requested quantity exceeds the product-specific per-30-day limits. Examples from the policy include age 18 years or older for most agents (with Verkazia ≥4 years for vernal keratoconjunctivitis), a required trial and failure of generic cyclosporine ophthalmic emulsion 0.05% for cyclosporine-related agents (or two ophthalmic corticosteroids for Eysuvis), prohibition on concurrent use with specified products (e.g., other ophthalmic cyclosporine products, Miebo, Tryptyr, Tyrvaya, Xiidra), and adherence to quantity limits such as 60 single-use vials per 30 days or one 2 mL/3 mL/5.5 mL bottle per 30 days depending on the product.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization and Approval Length

Prior authorization is required via the pharmacy benefit for the dry eye medications listed in this policy. Approvals may be granted for up to 12 months for initial and re-authorization when drug-specific criteria are met and chart notes document continued positive clinical response.

Step Therapy

Required Prior Trials

For several cyclosporine and related agents, a trial and failure of generic cyclosporine ophthalmic emulsion 0.05% is required unless contraindicated or clinically inappropriate. Document the contraindication or rationale for bypassing the required trial in the medical record.

Documentation Required

Medical Record Documentation

Submit office visit notes that document the diagnosis, relevant history, physical evaluation, and medication history to support medical necessity for all requests.

Billing Rule

Concurrent Therapy and Quantity Limits

Concurrent use of an ophthalmic cyclosporine product with another ophthalmic cyclosporine product or other specified agents is not allowed. Examples of non‑allowed concurrent therapy include combinations of Cequa, Restasis, Vevye, or Verkazia with each other, and concurrent use with Miebo (perfluorohexyloctane ophthalmic solution), Tryptyr (acoltremon ophthalmic solution), Tyrvaya (varenicline solution nasal spray), or Xiidra (lifitegrast ophthalmic solution). Prescribed quantity limits: Cequa and Tryptyr — limited to 60 single‑use vials per 30 days (Tryptyr may alternatively be limited to one 5.5 mL bottle per 30 days); Miebo — limited to one 3 mL bottle per 30 days; Xiidra — limited to one 2 mL bottle per 30 days or 60 single‑use containers per 30 days; Restasis and Vevye — follow the product‑specific quantity limits as listed. Requests exceeding these quantity limits or for disallowed concurrent combinations may be denied.

Examples of prohibited concurrent agents: Cequa, Restasis, Vevye, Verkazia, Miebo, Tryptyr, Tyrvaya, Xiidra
Cequa: limit 60 single‑use vials per 30 days
Tryptyr: limit 60 single‑use vials per 30 days OR one 5.5 mL bottle per 30 days
Miebo: limit one 3 mL bottle per 30 days
Xiidra: limit one 2 mL bottle per 30 days or 60 single‑use containers per 30 days

Key Definitions

Dry eye disease (DED)

Dry eye disease (DED) definitionA chronic condition caused by reduced tear production or excessive tear evaporation leading to ocular surface damage and symptoms such as burning, foreign body sensation, photophobia, and fluctuating vision.

EtiologyMay result from aqueous-deficient (reduced tear production) or evaporative (increased tear evaporation) mechanisms, including lacrimal or Meibomian gland dysfunction.

Common symptomsStinging/burning, gritty or scratchy sensation, itching, redness, sensitivity to light, blurred or fluctuating vision.

Diagnosis considerationsBased on history and tests such as ocular surface staining, tear breakup time, and tear osmolarity; referral to eye specialist may be required.

Meibomian gland dysfunction

Meibomian gland dysfunction (MGD) definitionA common cause of evaporative dry eye due to dysfunction of Meibomian glands affecting the lipid layer of the tear film.

PrevalencePresent in approximately 21.2% overall; higher prevalence in older adults (52%-61% in those >65 years).

Clinical noteMany individuals with MGD are asymptomatic; dysfunction contributes to tear film instability, inflammation, and ocular surface damage.

OpenPayer

Dry Eye Disease Medications (Pharmacy)

Coverage Criteria for Dry Eye Disease Medications

Coding and Quantity Limits

Provider Requirements and Prior Authorization

Background

Key Definitions

Policy Revision History