Tyrvaya (varenicline solution)
Indications for Prior Authorization
Tyrvaya (varenicline solution) nasal spray
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For diagnosis of Dry Eye Disease
Indicated for the treatment of the signs and symptoms of dry eye disease.
Criteria
Tyrvaya
For initial authorization request, approve through 12/31/2039 For reauthorization request, bypass criteria review and approve through 12/31/2039
Prior Authorization
Length of Approval: When approved; no reauthorization required
- Diagnosis of dry eye disease AND
- Trial and failure, contraindication, or intolerance to one of the following:
- Brand Restasis (cyclosporine 0.05%)
- Xiidra (lifitegrast)
P & T Revisions
1970-01-01, 2025-05-27, 2024-09-04, 2024-05-29, 2023-10-26, 2023-09-10, 2022-06-01, 2021-11-17
References
- Tyrvaya Prescribing Information. Oyster Point Pharma, Inc. Princeton, NJ. October 2021.
- American Academy of Ophthalmology. Dry Eye Syndrome Preferred Practice Pattern. October 2018. Available at https://www.aaojournal.org/article/S0161-6420(18)32650-2/fulltext#tbl3. Accessed November 4, 2021.
- Wood, S., Mian, S. Diagnostic Tools for Dry Eye Disease. Available at https://www.touchophthalmology.com/wp-content/uploads/sites/16/2017/01/Diagnostic-Tools-for-Dry-Eye-Disease_1.pdf. Accessed Nov 9. 2021.
- Zeev, M., Miller, D, et al. Diagnosis of dry eye disease and emerging technologies. Clin Ophthalmol 2014;8:581-590. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3964175/#b16-opth-8-581. Accessed November 9, 2021.
Revision History
- 2025-05-27: Removing reauthorization requirement as part of extended reauthorization program.
- 2024-09-04: update guideline
- 2024-05-29: update guideline
- 2023-10-26: Program update to standard reauthorization language. No changes to clinical intent.
- 2023-09-10: 2023 Annual Review.
- 2022-06-01: Removed requirement for paid claims/submission of medical records.
- 2021-11-17: 2022 New PA UM Criteria
HEALTHY LIVING