Pharmacy Prior Authorization Criteria

Vevye (cyclosporine ophthalmic solution 0.1%)

For diagnosis of Dry Eye Disease
Indicated for the treatment of the signs and symptoms of dry eye disease.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

AND

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

Patient demonstrates positive clinical response to therapy (e.g., increased tear production or improvement in dry eye symptoms).

2025-01-03, 2024-02-05

Vevye Prescribing Information. Alliance Medical Products, Inc. Irvine, CA. May 2023.
American Academy of Ophthalmology. Dry Eye Syndrome Preferred Practice Pattern. November 2018. Available at: https://www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Accessed January 6, 2024.
Xiidra [package insert]. Hanover, NJ: Novartis Pharmaceuticals Corporation: June 2020.
Restasis [package insert]. Irvine, CA: Allergan, Inc.; July 2017
Restasis MultiDose [package insert]. Irvine, CA: Allergan, Inc.; October 2016.
Tyrvaya [package insert]. Princeton NJ: Oyster Point Pharma, Inc; October 2021
Cequa [package insert]. Cranbury, NJ: Sun Pharmaceutical Industries, Inc; December 2022.
Miebo [package insert]. Bridgewater, NJ: Bausch & Lomb Americas Inc; May 2023.
ClinicalTrials.gov. CyclASol for the Treatment of Moderate to Severe dry-eye disease (DED). Avaialble at: https://www.clinicaltrials.gov/study/NCT02617667?cond=NCT02617667&rank=1. Accessed January 6, 2024.
ClinicalTrials.gov. ESSENCE 2: CyclASol for the Treatment of Signs and Symptoms of Dry Eye Disease (DED). Avaialble at: https://www.clinicaltrials.gov/study/NCT04523129?cond=nct04523129&rank=1. Accessed January 6, 2024.