Pharmacy Prior Authorization Criteria

Dry Eye Disease Agents

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.

Miebo (perfluorohexyloctane ophthalmic solution)

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

Restasis (cyclosporine 0.05%) ophthalmic emulsion

• For diagnosis of Keratoconjunctivitis sicca
  Indicated to increase tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca. Increased tear production was not seen in patients currently taking topical anti-inflammatory drugs or using punctal plugs.

Cequa (cyclosporine 0.09%) ophthalmic solution

• For diagnosis of Keratoconjunctivitis sicca
  Indicated to increase tear production in patients with keratoconjunctivitis sicca (dry eye).

Xiidra (lifitegrast)

• For diagnosis of Dry eye disease
  Indicated for the treatment of the signs and symptoms of dry eye disease (DED).

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

Tryptyr

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of dry eye disease

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)

Miebo

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

Brand Restasis, Generic cyclosporine 0.05% ophthalmic emulsion (Tier 1*)

NOTE: *This criteria is to be used for generic cyclosporine 0.05% ophthalmic emulsion that is on Tier 1 ONLY. This criteria does NOT apply to generic cyclosporine 0.05% ophthalmic emulsion on Tier 2 or Tier 3. 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

• One of the following:
• Diagnosis of moderate to severe keratoconjunctivitis sicca (dry eye)
OR
• Diagnosis of Sjogren syndrome with suppressed tear production due to ocular inflammation
AND
• One of the following [4, A]:
• Patient will not be using concurrent topical ophthalmic anti-inflammatory drugs (e.g., corticosteroids, NSAIDs [nonsteroidal anti-inflammatory drugs])
OR
• Topical ophthalmic anti-inflammatory drugs will only be used concurrently for a short period (up to 8 weeks) while transitioning to monotherapy with the requested drug

Generic cyclosporine 0.05% ophthalmic emulsion (Tier 2 or Tier 3*)

Note: *This criteria is to be used for generic cyclosporine 0.05% ophthalmic emulsion that is on Tier 2 or Tier 3 ONLY. This criteria does NOT apply to generic cyclosporine 0.05% ophthalmic emulsion on Tier 1. For initial authorization request, approve through 12/31/2039 For reauthorization request, bypass criteria review and approve through 12/31/2039 For state-mandated plans in Illinois or other states where applicable: Step therapy requirements do NOT apply. Beginning January 1, 2026, step therapy requirements or use of the authorization of alternative covered medications in a manner that effectively creates a step therapy requirement will not be imposed.

Prior Authorization

Length of Approval: When approved; no reauthorization required

• One of the following:
• Diagnosis of moderate to severe keratoconjunctivitis sicca (dry eye)
OR
• Diagnosis of Sjogren syndrome with suppressed tear production due to ocular inflammation
AND
• One of the following [4, A]:
• Patient will not be using concurrent topical ophthalmic anti-inflammatory drugs (e.g., corticosteroids, NSAIDs [nonsteroidal anti-inflammatory drugs])
OR
• Topical ophthalmic anti-inflammatory drugs will only be used concurrently for a short period (up to 8 weeks) while transitioning to monotherapy with the requested drug
AND
• All of the following
• At least 6 months use of brand Restasis within the previous 365 days (document drug, duration, and date of use)
AND
• Documentation provided stating that brand Restasis has not been effective
AND
• Justification provided for why the generic is expected to provide benefit when brand Restasis has not been shown to be effective

Generic cyclosporine 0.05% ophthalmic emulsion

Non Formulary

Length of Approval: 12 Month(s)

• One of the following:
• Diagnosis of moderate to severe keratoconjunctivitis sicca (dry eye)
OR
• Diagnosis of Sjogren syndrome with suppressed tear production due to ocular inflammation
AND
• One of the following [4, A]:
• Patient will not be using concurrent topical ophthalmic anti-inflammatory drugs (e.g., corticosteroids, NSAIDs [nonsteroidal anti-inflammatory drugs])
OR
• Topical ophthalmic anti-inflammatory drugs will only be used concurrently for a short period (up to 8 weeks) while transitioning to monotherapy with the requested drug
AND
• All of the following
• Paid claims or submission of medical records (e.g., chart notes) confirming at least 6 months use of brand Restasis within the previous 365 days (document drug, duration, and date of use)
AND
• Submission of documentation provided stating that brand Restasis has not been effective
AND
• Submission of justification provided for why the generic is expected to provide benefit when brand Restasis has not been shown to be effective

Cequa

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 keratoconjunctivitis sicca (dry eye)

Xiidra

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

Eysuvis

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
• Prescribed by or in consultation with one of the following:
• Ophthalmologist
• Optometrist

P & T Revisions

2025-12-15, 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.
3. Miebo Prescribing Information. Bausch & Lomb Americas Inc. Bridgewater, NJ. May 2023.
4. Restasis Prescribing Information. Allergan Inc. Irvine, CA. July 2017.
5. Cequa Prescribing Information. Sun Pharmaceutical Industries, Inc. Cranbury, NJ. March 2021
6. Xiidra Prescribing Information. Novartis Pharmaceuticals Corporation. East Hanover, NJ. July 2020.
7. Eysuvis prescribing information. Kala Pharmaceuticals, Inc. Watertown, MA. November 2020.

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End Notes

1. B. The FDA-approved indication states that during clinical trials, increased tear production was not seen in patients currently taking topical anti-inflammatory drugs or using punctal plugs. [4]

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Revision History

• 2025-12-15: Added IL statute operational note.
• 2025-08-05: New UM PA Criteria

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