CurrentUnitedHealthcarePolicy N/A

Prior authorization and reauthorization criteria for prescription therapies for dry eye disease and keratoconjunctivitis sicca

Prior authorization and reauthorization criteria for prescription medications used to treat dry eye disease and keratoconjunctivitis sicca for UnitedHealthcare members; affects prescribers and pharmacists submitting PA requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization and reauthorization criteria for prescription therapies for dry eye disease and keratoconjunctivitis sicca

Policy CodePolicy N/A

Change TypeMaterial updates to authorization duration and concomitant therapy restrictions

Effective DateOct 1, 2025

Next Review DateJul 1, 2025

Key ActionSubmit prior authorization showing diagnosis of moderate to severe keratoconjunctivitis sicca or dry eye disease and documentation that the medication will not be used with another prescription dry eye product.

SourceLink

POLICY UPDATE CHANGES

Initial authorization duration updated to 12 months (previously 6 months) and reauthorization criteria updated to 12 months.

Concomitant therapy restriction: medication will not be used in combination with another prescription product for dry eye disease or keratoconjunctivitis sicca.

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

Specific agents (Cequa, Miebo, Restasis, Restasis MultiDose, Tyrvaya, Vevye, Xiidra) are listed within the program for prior authorization review.

12 monthsauthorization period

7listed products

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.

typically excluded agents

7/2025most recent review

Coverage Criteria for Dry Eye Disease Therapies

Initial Authorization

Covered when ALL of the following are met:

Initial Authorization: 1) Prescription is for Cequa, Miebo, Restasis, Restasis MultiDose, Tyrvaya, Vevye or Xiidra; 2) Diagnosis of ONE of: moderate to severe keratoconjunctivitis sicca OR dry eye disease; 3) Medication will not be used in combination with another prescription product for dry eye disease or keratoconjunctivitis sicca; 4) Authorization period: 12 months.

Cequa, Restasis MultiDose and Vevye are typically excluded from coverage (see exclusions).

Reauthorization

Covered when ALL of the following are met:

Reauthorization: 1) Patient has demonstrated clinically significant improvement with therapy; 2) Medication will not be used in combination with another prescription product for dry eye disease or keratoconjunctivitis sicca; 3) Authorization period: 12 months.

Clinical improvement must be documented in the medical record.

The following agents are noted as typically excluded from coverage: Cequa, Restasis MultiDose, and Vevye. This operational exclusion is called out in the program guidance and may affect prior authorization determinations and claim adjudication.

Use of a listed prescription medication for dry eye disease or keratoconjunctivitis sicca in combination with another prescription product for the same condition is not permitted under the criteria and may be considered not medically necessary; requests that involve concomitant prescription dry eye therapy are subject to denial.

Providers should ensure the requested agent will be used as a single prescription therapy for dry eye disease and document the treatment plan accordingly. Lack of documentation or evidence of combination therapy may lead to adverse coverage decisions.

Referenced Products and Codes

Referenced clinical products and package inserts (not billing codes)mixed

No codes listed

Provider Actions, Documentation and Utilization Controls

Prior Authorization

Prior Authorization Required

Prior authorization is required for Cequa, Miebo, Restasis, Restasis MultiDose, Tyrvaya, Vevye, and Xiidra. Initial approvals are issued for 12 months. Prior authorization determinations may also rely on previous claim/medication history, diagnosis codes (ICD-10), and claim logic.

Affected products: Cequa, Miebo, Restasis, Restasis MultiDose, Tyrvaya, Vevye, Xiidra
Initial approval duration: 12 months
UnitedHealthcare may apply prior authorization medical necessity review and rely on prior claim/medication history or diagnosis codes

Denial Risk

Concomitant Therapy and Exclusions

Medication must not be used in combination with another prescription product for dry eye disease or keratoconjunctivitis sicca. Requests that propose concomitant use with another prescription dry eye therapy should be denied.

Background

This policy addresses prescription therapies used to treat signs and symptoms of dry eye disease and keratoconjunctivitis sicca. Included agents encompass cyclosporine ophthalmic formulations (for example, Cequa, Restasis, Restasis MultiDose, Vevye), lifitegrast (Xiidra), varenicline nasal spray (Tyrvaya), and perfluorohexyloctane (Miebo). These products are indicated to increase tear production or reduce ocular surface inflammation and tear film instability associated with dry eye.

Authorization decisions reflect clinical presentation and documented benefit: approval is contingent on meeting diagnostic criteria for moderate to severe keratoconjunctivitis sicca or dry eye disease and adherence to utilization controls described in this policy. Note that some cyclosporine formulations (Cequa, Restasis MultiDose and Vevye) are identified as typically excluded from coverage and authorization is generally issued for 12 months when criteria are met.

Definitions

Keratoconjunctivitis sicca / dry eye disease — definition

TermKeratoconjunctivitis sicca (dry eye disease)

DefinitionA disorder in which tear production is presumed suppressed due to ocular inflammation, leading to symptoms and signs of dry eye disease; agents such as topical cyclosporine, lifitegrast, varenicline nasal spray, and perfluorohexyloctane are used to increase tear production or treat signs and symptoms.

Common prescription agents referencedCequa (cyclosporine 0.09%), Restasis/Restasis MultiDose (cyclosporine 0.05%), Vevye (cyclosporine 0.1%), Xiidra (lifitegrast 5%), Tyrvaya (varenicline nasal spray), Miebo (perfluorohexyloctane)

Typical clinical presentationModerate to severe symptoms of ocular surface irritation and reduced tear production attributed to ocular inflammation.

Role in policyDiagnosis of moderate to severe keratoconjunctivitis sicca or dry eye disease is required for initial authorization of listed prescription therapies.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization and reauthorization criteria for prescription therapies for dry eye disease and keratoconjunctivitis sicca

Policy CodePolicy N/A

Change TypeMaterial updates to authorization duration and concomitant therapy restrictions

Effective DateOct 1, 2025

Next Review DateJul 1, 2025

SourceLink

On This Page

Operational rule: no concomitant prescription therapy for dry eye disease/keratoconjunctivitis sicca
Denial condition: any request that indicates use in combination with another prescription product for the same indication

Documentation Required

Required Clinical Documentation

Document the diagnosis and clinical response for initial and reauthorization requests. Include evidence of moderate to severe keratoconjunctivitis sicca (or equivalent dry eye disease diagnosis) for initial approvals, and documented clinically significant improvement for reauthorization.

Initial request documentation: diagnosis of moderate to severe keratoconjunctivitis sicca or dry eye disease; relevant clinical findings supporting severity
Reauthorization documentation: evidence the patient has demonstrated clinically significant improvement on therapy
Administrative note: state mandates, federal requirements, and member-specific benefit plans may affect coverage; Cequa, Restasis MultiDose, and Vevye may be excluded per some benefit plans

Step Therapy

Utilization Controls

Utilization controls may include supply limits and step-therapy. Exceptions to dosing or supply limits may be considered with supporting clinical justification. Prior authorization medical necessity rules may be applied.

Supply limits may be enforced
Step therapy rules may apply
Exceptions to supply/dosing limits can be requested with clinical justification

Denial Risk

Administrative Denial Risks

Administrative denials can occur if prior authorization criteria are not met, required documentation is missing, the request relies solely on supply limits without clinical support, or if the member's benefit excludes the product.

Denial risks: missing PA criteria or documentation
Denial risks: exceeding supply limits without justification
Denial risks: product excluded by member-specific benefits (e.g., Cequa, Restasis MultiDose, Vevye)