Pharmacy Prior Authorization Criteria

Eysuvis (loteprednol etabonate ophthalmic suspension)

Indications for Prior Authorization

Eysuvis (loteprednol etabonate ophthalmic suspension)

• For diagnosis of Dry eye disease (DED)
  Indicated for the short-term (up to two weeks) treatment of the signs and symptoms of dry eye disease.

Criteria

Eysuvis

Prior Authorization (Initial Authorization)

Length of Approval: 14 Day(s)
For diagnosis of Dry Eye Disease

• Diagnosis of dry eye disease
AND
• Prescribed by or in consultation with one of the following:
• Ophthalmologist
• Optometrist

Eysuvis

Prior Authorization (Reauthorization)

Length of Approval: 14 Day(s)
For diagnosis of Dry Eye Disease

• Patient demonstrates positive clinical response to therapy (e.g., improvement in dry eye symptoms)
AND
• Prescribed by or in consultation with one of the following:
• Ophthalmologist
• Optometrist

P & T Revisions

1970-01-01, 2024-03-25, 2023-12-06, 2022-01-10, 2021-05-04, 2021-02-04

References

1. Eysuvis prescribing information. Kala Pharmaceuticals, Inc. Watertown, MA. November 2020.
2. Per clinical consult with ophthalmologist, December 21, 2020.
3. Shtein, RM. Dry eye disease. In: Post T, ed. UpToDate. UpToDate; 2020. Accessed December 16, 2020. www.uptodate.com
4. Micromedex Healthcare Series [database on the Internet]. Greenwood Village (CO): IBM Corporation.; Updated periodically. Available by subscription at: https://www.micromedexsolutions.com/. Accessed December 16, 2020.

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Revision History

• 2024-03-25: 2024 Annual Review
• 2023-12-06: Updated reauth verbiage to remove documentation of
• 2022-01-10: Updated to add EHB formulary, no changes to criteria
• 2021-05-04: Removed embedded step requirement through loteprednol or fluorometholone.
• 2021-02-04: New Program

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