Pharmacy Prior Authorization Criteria

Tryptyr (acoltremon ophthalmic solution)

Indications for Prior Authorization

Tryptyr (acoltremon ophthalmic solution)

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

Criteria

Tryptyr

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of dry eye disease
AND
• Trial and failure, contraindication, or intolerance to both of the following:
• Restasis (cyclosporine 0.05%)
• Xiidra (lifitegrast)

Tryptyr

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)

P & T Revisions

2025-08-05

References

1. Tryptyr Prescribing Information. Alcon Laboratories, Inc. Fort Worth, TX. May 2025.
2. American Academy of Ophthalmology. Dry Eye Syndrome Preferred Practice Pattern. February 2024. https://www.aao.org/education/preferred-practice-pattern/dry-eye-syndrome-ppp-2023. Accessed July 28, 2025.

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Revision History

• 2025-08-05: New UM PA Criteria

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