Pharmacy Prior Authorization Criteria

Xiidra (lifitegrast)

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

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

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)

2024-02-16, 2023-12-01, 2023-02-02, 2022-01-28, 2021-09-28, 2021-06-02, 2021-05-26, 2021-05-25, 2020-05-26, 2020-03-25

Xiidra Prescribing Information. Novartis Pharmaceuticals Corporation. East Hanover, NJ. July 2020.
American Academy of Ophthalmology Preferred Practice Pattern Cornea/External Disease Committee. Dry Eye Syndrome PPP - 2018. November 2018. https://www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Accessed January 28, 2022.

As disease severity increases, aqueous enhancement of the eye using topical agents is appropriate (i.e., emulsions, gels, and ointments can be used). Topical cyclosporine, topical corticosteroids, topical lifitegrast, systemic omega-3 fatty acid supplements, punctual plugs and spectacle side shields/moisture chambers may also be considered in addition to aqueous enhancement therapies in patients who need additional symptom management. [2]

2024-02-16: 2024 Annual Review
2023-12-01: Program update to standard reauthorization language. No changes to clinical intent.
2023-02-02: 2023 Annual Review.
2022-01-28: 2022 Annual Review
2021-09-28: 2021 Annual Review, no changes to criteria.
2021-06-02: 2021 Annual Review, no changes to criteria.
2021-05-26: Addition of EHB formulary to guideline, no changes to criteria
2021-05-25: Addition of EHB formulary to guideline, no changes to criteria
2020-05-26: 2020 Annual Review, no changes to criteria
2020-03-25: Updated to remove OTC requirement, updated background references.