ModifiedUnitedHealthcarePolicy N/A

Pa Notification Dry Eye Disease

Defines UnitedHealthcare Pharmacy clinical notification (prior authorization) coverage criteria for specific prescription ophthalmic therapies for dry eye disease or keratoconjunctivitis sicca (Cequa, Miebo, Restasis, Restasis MultiDose, Tryptyr, Tyrvaya, Vevye, Xiidra), including initial authorization, reauthorization, prohibited concomitant use, authorization duration, and additional clinical/billing rules.

Policy Summary

PayerUnitedHealthcare

PolicyPa Notification Dry Eye Disease

Policy CodePolicy N/A

Change TypeModified (adds products; updates duration; adds concomitant-use prohibition)

Effective DateJan 17, 2026

Next Review Date

Key ActionSubmit prior authorization/notification per UnitedHealthcare Pharmacy Clinical Pharmacy Programs; approvals (initial and reauthorization) will be issued for 12 months when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Tryptyr added to the policy.

Initial and reauthorization approval period standardized to 12 months.

Concomitant therapy prohibition added.

Miebo and Vevye added to criteria.

Tyrvaya previously added to policy.

8Drugs listed

12 moAuthorization duration

2Accepted diagnoses for initial approval