CEQUA (cyclosporine)

SELF-ADMINISTRATION - Ophthalmic

Indications for Prior Authorization:
  • Indicated to increase tear production in patients with keratoconjunctivitis sicca (dry eye)
All of the following must be met as a condition(s) for coverage:
  • Diagnosis of keratoconjunctivitis sicca (dry eye), AND
  • Trial and failure of artificial tears as confirmed by chart notes, AND
  • Trial and failure of both Restasis® and Xiidra®
Dosing:
  • Instill one drop of Cequa™ twice daily (approximately 12 hours apart) into each eye
Approval:
  • 1 year

 

Last review date: February 18, 2020