CurrentUnitedHealthcarePolicy N/A

Prior authorization criteria for prescription ophthalmic treatments for dry eye (keratoconjunctivitis sicca)

Defines UnitedHealthcare prior authorization and medical necessity criteria for several prescription ophthalmic treatments for dry eye disease (e.g., Cequa, Restasis MultiDose, Tyrvaya, Vevye, Xiidra) and who may prescribe them. Applies to members under UnitedHealthcare plans governed by this program.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization criteria for prescription ophthalmic treatments for dry eye (keratoconjunctivitis sicca)

Policy CodePolicy N/A

Change TypeMaterial revisions and additions (medication additions, step therapy clarified, auth duration standardized)

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization documenting diagnosis and trials of two listed comparator products before initiating therapy; authorization issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

Miebo and Vevye were added as options in the program.

Initial authorization period updated to 12 months for covered medications.

Step therapy requirements updated to include failure, contraindication, or intolerance to two listed comparator products prior to approval.

Concomitant use with other prescription products for dry eye/keratoconjunctivitis sicca is not allowed for initial or reauthorization.

12 monthsauthorization duration

>=2required prior failures

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.

Prescribersauthorized prescribers

Coverage and Medical Necessity Criteria

Initial Therapy (Cequa, Restasis MultiDose, Vevye)

Covered when ALL of the following are met:

Initial Authorization - Cequa/Restasis MultiDose/Vevye: (1) Diagnosis of moderate to severe keratoconjunctivitis sicca OR moderate to severe dry eye disease; (2) Medication is not prescribed to manage peri‑operative elective eye surgery (e.g., LASIK); (3) History of failure, contraindication, or intolerance to two of the following comparators: Miebo; Restasis single‑dose vials; Xiidra; (4) Medication will not be used in combination with another prescription product for dry eye/keratoconjunctivitis sicca (examples include Miebo, Restasis single‑dose vials, Tyrvaya, Xiidra); (5) Prescribed by or in consultation with an ophthalmologist, optometrist, or rheumatologist.n/a

Authorization issued for 12 months

Initial Therapy (Tyrvaya)

Covered when ALL of the following are met:

Initial Authorization - Tyrvaya: (1) Diagnosis of moderate to severe keratoconjunctivitis sicca OR moderate to severe dry eye disease; (2) Medication is not prescribed to manage peri‑operative elective eye surgery (e.g., LASIK); (3) History of failure, contraindication, or intolerance to two of the following comparators (examples listed include Miebo, Restasis single‑dose vials, Xiidra); (4) Medication will not be used in combination with another prescription product for dry eye/keratoconjunctivitis sicca (examples include Cequa, Miebo, Restasis, Vevye, Xiidra); (5) Prescribed by or in consultation with an ophthalmologist, optometrist, or rheumatologist.n/a

Authorization issued for 12 months

Reauthorization

Covered when ALL of the following are met:

Reauthorization: (1) Patient has demonstrated clinically significant improvement with continued therapy; (2) Medication is not being used in combination with another prescription product for dry eye disease or keratoconjunctivitis sicca (examples include Cequa, Miebo, Restasis, Vevye, Xiidra).n/a

Authorization issued for 12 months

Requests for initial authorization of prescription topical therapies covered under this program are not approved when prescribed to manage peri‑operative elective eye surgery (for example, LASIK). This exclusion specifically applies to initial authorization determinations for agents such as Cequa, Restasis MultiDose, Vevye, and Tyrvaya; use in the peri‑operative/elective refractive surgery setting does not meet the program’s coverage criteria.

Concomitant use of a covered prescription topical agent with another prescription product for dry eye/keratoconjunctivitis sicca is not allowed. The policy lists examples of products that must not be used together (for example, Miebo, Restasis single‑dose vials, Tyrvaya, Cequa, Vevye, Xiidra). Requests where the medication is intended to be used in combination with any other prescription dry eye/keratoconjunctivitis sicca agent will be considered not medically necessary and are not eligible for initial authorization or reauthorization under this program.

Diagnosis and Procedure Coding

ICD-10 (diagnosis codes)ICD-10

No codes listed

Prescriber Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for initial and continuation therapy. Initial approval is contingent upon a qualifying diagnosis (moderate to severe keratoconjunctivitis sicca or moderate to severe dry eye disease), not being prescribed for peri‑operative/elective eye surgery (e.g., LASIK), and meeting step‑therapy requirements (failure, intolerance, or contraindication to two specified comparator products). Authorizations are issued for 12 months.

Authorization duration: 12 months
Supply limits and prior authorization notification may apply

Step Therapy

Step Therapy Requirement

Step therapy: patient must have a history of failure, intolerance, or contraindication to two of the specified comparator products before approval will be granted.

Required comparators (examples listed in policy): Miebo, Restasis single‑dose vials, Xiidra, (and where applicable) Cequa, Vevye, Tyrvaya

Key Definitions

Keratoconjunctivitis sicca / dry eye disease — definition and 'moderate to severe' threshold

ConditionKeratoconjunctivitis sicca (dry eye disease): a disorder of reduced tear production or unstable tear film often associated with ocular inflammation.

Severity threshold required for coverageDiagnosis must be moderate to severe keratoconjunctivitis sicca OR moderate to severe dry eye disease.

Clinical manifestation referenced in policySymptoms/signs include reduced tear production and ocular inflammation; prescription topical cyclosporine and lifitegrast products are indicated for these presentations.

Use excluded in peri‑operative settingTherapy prescribed to manage peri‑operative elective eye surgery (e.g., LASIK) is excluded from initial authorization.

Documentation requirementClinical record must support the diagnosis of moderate to severe disease when seeking prior authorization.

Background and Clinical Context

Prescription topical cyclosporine and lifitegrast products included in this program (examples: Cequa, Restasis MultiDose, Xiidra, with other agents noted elsewhere in the policy) are indicated to increase tear production or to treat the signs and symptoms of dry eye disease (keratoconjunctivitis sicca), a condition that may be associated with ocular inflammation. Coverage under this policy is aligned to clinical diagnosis (typically moderate to severe disease), documented therapeutic response, and compliance with any required prior‑therapy steps.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization criteria for prescription ophthalmic treatments for dry eye (keratoconjunctivitis sicca)

Policy CodePolicy N/A

Change TypeMaterial revisions and additions (medication additions, step therapy clarified, auth duration standardized)

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization documenting diagnosis and trials of two listed comparator products before initiating therapy; authorization issued for 12 months.

SourceLink

On This Page

Documentation Required

Required Documentation

Documentation required to support the request includes clinical evidence of diagnosis severity and prior therapy history. Include dates, doses, duration, and reason for discontinuation (failure, intolerance, or contraindication) for each comparator trial.

Clinical documentation of diagnosis (moderate to severe keratoconjunctivitis sicca or moderate to severe dry eye disease)
Medication history showing trials of two comparators with start/stop dates and reason for failure/intolerance/contraindication

Documentation Required

Prescriber and Consultation Requirements

Prescriber documentation: the medication must be prescribed by — or in consultation with — an appropriate specialist. Include the prescriber type on the request and documentation of consultation if the prescriber is not one of the listed specialists.

Acceptable prescribers: Ophthalmologist, Optometrist, Rheumatologist
If prescribed by another provider, supply documentation of consultation with one of the acceptable specialists

Denial Risk

Denial Triggers

Triggers for denial: requests will be denied if the medication is intended for peri‑operative/elective eye surgery, is being used concomitantly with another prescription product for dry eye/keratoconjunctivitis sicca, or lacks documented trials of required comparator therapies or a supported diagnosis.

Peri‑operative/elective eye surgery indication (e.g., LASIK) — not eligible
Concomitant use with another prescription product for dry eye (e.g., Miebo, Restasis, Cequa, Vevye, Xiidra, Tyrvaya)
Insufficient documentation of trials of two required comparator products or unsupported diagnosis/history

Denial Risk

Automated Denial Risk

Automated denial risk: UnitedHealthcare may use prior claim/medication history, diagnosis codes (ICD‑10), and claim logic to automatically deny requests that are not supported by the member's claims or medication history. Ensure submitted claims and diagnosis codes align with the requested authorization.

Automated approval/denial processes may be applied based on claims and medication history
Ensure ICD‑10 diagnosis codes and medication history in the request support the approval criteria