CurrentPremera BlueCrossPolicy N/A

Dry Eye Disease Medications (Pharmacy Policy 5.01.661)

Defines pharmacy benefit medical necessity criteria for prescription medications used to treat signs and symptoms of dry eye disease for covered members under Premera BlueCross (pharmacy benefit).

Policy Summary

PayerPremera BlueCross

PolicyDry Eye Disease Medications (Pharmacy Policy 5.01.661)

Policy CodePolicy N/A

Change TypeNew policy created (moved drugs from 5.01.605)

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization per the pharmacy benefit; initial and reauthorization approvals may be granted up to 12 months when criteria and response are documented.

SourceLink

POLICY UPDATE CHANGES

New policy created to manage dry eye disease medications under Pharmacy Policy 5.01.661.

11+named drugs listed with coverage criteria

60single-use vials per 30 days

12initial auth length (months)

18reference items

Coverage Criteria for Dry Eye Disease Medications

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Drug-specific medical necessity

Covered when ALL of the following are met

General applicable conditions: Individual is being treated for the signs and symptoms of dry eye disease AND is aged 18 years or older (unless otherwise specified)age >=18 years

Applies to most agents; Verkazia has different age criteria

Prior therapy requirement for cyclosporine-class and others: Has tried and failed generic cyclosporine ophthalmic emulsion 0.05% unless there is a contraindication to cyclosporine ophthalmictrial and failure of generic cyclosporine 0.05% unless contraindicated

Specified for Cequa, Miebo, Restasis, Vevye, Xiidra (generic) and others

No concurrent use of specified agents: The requested product is not being used concurrently with another ophthalmic cyclosporine product or with listed agents (e.g., Cequa, Restasis, Vevye, Miebo, Tryptyr, Tyrvaya, Xiidra)no concurrent use

Product-specific lists included in each drug's criteria

Product-specific quantity limits: Prescribed quantity is within product-specific limits (examples: 60 single-use vials per 30 days; one 3 ml bottle per 30 days; one 2 ml bottle per 30 days; or one 5.5 ml bottle per 30 days)see thresholds

Limits vary by product

Verkazia specific criteria: Indicated for vernal keratoconjunctivitis when individual is aged 4 years or older AND has moderate-to-severe vernal keratoconjunctivitisage >=4 years

Different age and indication than other entries

Eysuvis steroid prior trials: For Eysuvis: individual has tried and failed two of: dexamethasone eye drops, loteprednol etabonate eye drops, or fluorometholone eye dropsfailure of two listed ophthalmic corticosteroids

Specific to Eysuvis

All uses of the listed ophthalmic agents that are not specifically described in this policy are considered investigational and are not covered under the pharmacy benefit.

Use of the agents included in this policy for indications outside those explicitly outlined (for example, diagnoses or clinical situations not specified in the drug-specific criteria) is investigational and not covered.

Requests for indications not described in the coverage criteria will be managed as investigational; documentation submitted must support that the request meets one of the policy’s listed, drug-specific medical necessity criteria to be considered for coverage.

Provider Requirements, Prior Authorization, and Reason for Denial

Prior Authorization

Prior Authorization Required

Prior authorization is required for medications covered under this policy. Initial authorizations may be approved for up to 12 months. Reauthorizations may also be approved for up to 12 months provided the drug-specific coverage criteria continue to be met and chart notes demonstrate ongoing positive clinical response to therapy.

Initial authorization duration: up to 12 months
Reauthorization duration: up to 12 months (requires documentation of continued clinical benefit)

Step Therapy

Step Therapy Expectations

Step therapy requirements apply for the agents in this policy. Unless contraindicated, members must have tried and failed generic cyclosporine ophthalmic emulsion 0.05% prior to approval of branded cyclosporine products (e.g., Cequa, Restasis, Vevye) and other specified agents. Some products in this policy require failure of one generic cyclosporine 0.05%; others require failure of two topical corticosteroid or other listed agents per the drug-specific criteria. Ensure prior use and failure (or documented contraindication) of the required agent(s) is included with the request.

Required step: trial and failure of generic cyclosporine ophthalmic emulsion 0.05% unless contraindicated (applies to Cequa, Restasis, Vevye, Xiidra, Miebo, and others as specified)
Some agents (e.g., Eysuvis) require failure of two alternative ophthalmic agents (dexamethasone, loteprednol etabonate, or fluorometholone) per drug-specific criteria
Concurrent use of another ophthalmic cyclosporine (e.g., Restasis, Cequa, Vevye), Miebo, Tryptyr, Tyrvaya, or Xiidra is not permitted

Documentation Required

Required Documentation

Submit complete medical records to support medical necessity. Incomplete documentation is a common cause for denial.

Office visit notes with diagnosis, relevant history, physical examination findings
Medication history documenting prior therapies tried, dates, duration, and reason for discontinuation (e.g., lack of efficacy, intolerance, or contraindication)
Chart notes showing current signs and symptoms of dry eye disease and clinical response to prior treatments
For reauthorization: documentation of continued clinical benefit from the requested agent

Denial Risk

Triggers for Denial

Requests may be denied if required criteria or documentation are missing or not met. Common denial triggers are listed below — review before submission to avoid delays.

Member is under the minimum age specified in the drug-specific criteria (most products require age ≥ 18 years; Verkazia is for age ≥ 4 years for vernal keratoconjunctivitis)
No documented trial and failure of required step therapy agents (e.g., generic cyclosporine ophthalmic emulsion 0.05%) and no documented contraindication
Concurrent use of disallowed products (e.g., two ophthalmic cyclosporine products or listed concurrent agents)
Missing or incomplete medical records (office notes, medication history, exam findings)
Requested quantity exceeds the policy limits (e.g., quantities greater than 60 single‑use vials per 30 days or greater than specified bottle limits)
For reauthorization: lack of documentation demonstrating ongoing clinical benefit

Background

Dry eye disease (DED) is a chronic disorder caused by either reduced tear production (aqueous-deficient) or increased tear evaporation, which leads to ocular surface inflammation and symptoms such as burning, gritty sensation, redness, and visual disturbance.

Diagnosis is based on clinical history and objective testing (for example, tear breakup time and ocular surface staining). Management ranges from basic measures like lubricating eye drops and eyelid hygiene to prescription therapies — including topical immunomodulatory agents, secretagogues, and procedural interventions — selected according to disease severity and underlying causes such as meibomian gland dysfunction.

Definitions

Dry eye disease — definition

DefinitionDry eye disease (DED) — a chronic condition caused by reduced tear production or excessive tear evaporation leading to ocular surface inflammation and symptoms such as burning, gritty sensation, redness, and visual disturbance.

CausesMay result from aqueous deficiency or increased tear evaporation; glands involved include lacrimal, Meibomian, and conjunctival goblet cells.

Diagnosis and symptomsDiagnosis based on history and tests (e.g., tear breakup time, ocular surface staining); common symptoms include stinging, photophobia, blurred vision, and ocular irritation.

Meibomian gland dysfunction — definition & relevance

DefinitionMeibomian gland dysfunction (MGD) — dysfunction of the Meibomian glands that contributes to evaporative dry eye by altering the lipid layer of the tear film.

PrevalencePresent in approximately 21.2% overall; 30%-35% of Whites and 33%-50% of East Asians; 52%-61% in patients over 65 years; up to two-thirds may be asymptomatic.

Clinical relevanceMGD reduces tear film quality and increases evaporation, contributing to tear film instability, ocular surface inflammation, and symptoms of DED.

OpenPayer

Dry Eye Disease Medications (Pharmacy Policy 5.01.661)

Coverage Criteria for Dry Eye Disease Medications

Coding and Quantity Limits

Provider Requirements, Prior Authorization, and Reason for Denial

Background

Definitions