CurrentUnitedHealthcarePolicy N/A

Prior authorization/notification criteria for prescription therapies for Dry Eye Disease and Keratoconjunctivitis Sicca

Prior authorization/notification criteria for topical and nasal prescription products (e.g., cyclosporine, lifitegrast, varenicline nasal spray, perfluorohexyloctane, acoltremon) used to treat dry eye disease or keratoconjunctivitis sicca for UnitedHealthcare members.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization/notification criteria for prescription therapies for Dry Eye Disease and Keratoconjunctivitis Sicca

Policy CodePolicy N/A

Change TypeMaterial updates (added product, clarified combination therapy prohibition, revised authorization duration)

Effective Date1/17/2026

Next Review DateN/A

Key ActionObtain prior authorization; approvals issued for 12 months when diagnosis meets criteria and the medication is not used concurrently with another prescription product for dry eye disease or keratoconjunctivitis sicca.

SourceLink

POLICY UPDATE CHANGES

Tryptyr was added to the criteria.

Initial authorization period updated to 12 months.

Requirement that medication not be used in combination with another prescription product for dry eye disease or keratoconjunctivitis sicca was added.

Statement that Cequa, Restasis MultiDose, Tryptyr and Vevye are typically excluded from coverage.

1/17/2026Effective date

12 monthsAuthorization duration

9Named products

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Cequa, Restasis MultiDose, Tryptyr, VevyeTypically excluded

Coverage Criteria for Dry Eye Disease and Keratoconjunctivitis Sicca

Initial Therapy

Covered when ALL of the following are met

Initial Authorization Criteria

Allowed Diagnoses: 1) Moderate to severe keratoconjunctivitis sicca OR 2) Dry Eye Disease
Concomitant therapy prohibition: Medication will not be used in combination with another prescription product for dry eye disease or keratoconjunctivitis sicca

Products covered under this criteria: Cequa, Miebo, Restasis, Restasis MultiDose, Tryptyr, Tyrvaya, Vevye or Xiidra (note: some named products are typically excluded from coverage per policy).

See exclusions for products typically excluded from coverage.

Reauthorization / Continuation Therapy

Reauthorization covered when ALL of the following are met

Reauthorization Criteria: Patient has demonstrated clinically significant improvement with therapy, AND medication is not used in combination with another prescription product for dry eye disease or keratoconjunctivitis sicca.

Authorization will be issued for 12 months.

The following products are typically excluded from coverage: Cequa, Restasis MultiDose, Tryptyr, and Vevye. Coverage for these agents may be limited by product-specific exclusions and subject to state mandates, federal requirements, and member-specific benefit plan terms.

Use of the requested medication in combination with another prescription product for dry eye disease or keratoconjunctivitis sicca is not allowed. Combination therapy for the same indication does not meet the coverage criteria and may result in denial of authorization.

Named Products and Codes

Named Productsmixed

Cequa	cyclosporine 0.09% ophthalmic solution
Miebo	perfluorohexyloctane
Restasis	cyclosporine 0.05% ophthalmic emulsion
Restasis MultiDose	cyclosporine 0.05% ophthalmic emulsion
Tryptyr	acoltremon ophthalmic solution
Tyrvaya	varenicline nasal spray
Vevye	cyclosporine 0.1%
Xiidra	lifitegrast 5% ophthalmic solution

Provider Actions, Prior Authorization and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization/notification required: approval is granted when one of the listed diagnoses is present and the medication is not used in combination with another prescription product. Authorization is issued for 12 months. State mandates, federal regulatory requirements, and member-specific benefit plan coverage may affect coverage. Note: Cequa, Restasis MultiDose, Tryptyr, and Vevye are typically excluded from coverage.

Affected products: Cequa*, Miebo, Restasis, Restasis MultiDose*, Tryptyr*, Tyrvaya, Vevye* , Xiidra
Authorization duration: 12 months
Coverage note: State mandates and member benefit plans may impact coverage

Step Therapy

Step / Automation Rules

Supply limits and prior authorization based on medical necessity or automated claim history may be applied. UnitedHealthcare may utilize automated approval and re-approval processes that rely on claim/medication history, ICD-10 diagnosis codes, and claim logic.

Background

Dry eye disease and keratoconjunctivitis sicca are conditions characterized by reduced tear production or ocular surface inflammation leading to symptoms of ocular surface dryness. Several topical and nasal prescription agents (for example, cyclosporine formulations, lifitegrast, varenicline nasal spray, perfluorohexyloctane, and acoltremon) are used to increase tear production or treat signs and symptoms of these conditions.

Definitions

keratoconjunctivitis sicca — definition

DefinitionKeratoconjunctivitis sicca: tear production presumed to be suppressed due to ocular inflammation.

Typical indicationsMedications such as Cequa (cyclosporine 0.09% ophthalmic solution), Restasis (cyclosporine 0.05% ophthalmic emulsion) and Restasis MultiDose are indicated to increase tear production in patients with keratoconjunctivitis sicca.

Clinical contextAssociated with ocular surface inflammation leading to reduced tear production and symptoms of dry eyes.

dry eye disease — definition

DefinitionDry eye disease: clinical condition causing signs and symptoms of ocular surface dryness treated with multiple prescription topical or nasal agents.

Typical indications

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization/notification criteria for prescription therapies for Dry Eye Disease and Keratoconjunctivitis Sicca

Policy CodePolicy N/A

Change TypeMaterial updates (added product, clarified combination therapy prohibition, revised authorization duration)

Effective Date1/17/2026

Next Review DateN/A

SourceLink

On This Page

Supply limits may apply
Prior authorization may be enforced as a medical necessity requirement
Automated approval/re-approval may use claim history, medication history, ICD-10 codes, and claim logic

Documentation Required

Acceptable Documentation Sources

UnitedHealthcare may approve initial and re-authorization requests based on acceptable documentation sources including previous claim and medication history, submitted diagnosis codes (ICD-10), and automated claim-logic determinations. Providers should ensure documentation or claims reflect the required diagnosis and absence of combination therapy when applicable.

Previous claim and medication history
Submitted ICD-10 diagnosis codes showing moderate to severe keratoconjunctivitis sicca or dry eye disease
Claim logic/automated adjudication evidence

Denial Risk

Denial Risks

Authorization can be denied if the documented diagnosis does not meet the required criteria (i.e., not moderate to severe keratoconjunctivitis sicca or dry eye disease) or if the medication is used in combination with another prescription product for the same condition. Coverage may also be unavailable for products that are typically excluded.

Denial if diagnosis does not match moderate to severe keratoconjunctivitis sicca or dry eye disease
Denial if medication used in combination with another prescription product for dry eye disease/keratoconjunctivitis sicca
Coverage may be unavailable for typically excluded products (Cequa, Restasis MultiDose, Tryptyr, Vevye)

Agents such as Miebo (perfluorohexyloctane), Tryptyr (acoltremon ophthalmic solution), Tyrvaya (varenicline nasal spray), Vevye (cyclosporine 0.1%), and Xiidra (lifitegrast 5% ophthalmic solution) are indicated to treat signs and symptoms of dry eye disease.

Clinical contextMay present with ocular surface inflammation and symptoms that can be managed with prescription topical or nasal therapies.