Pharmacy Prior Authorization Criteria

Cequa (cyclosporine 0.09%)

Indications for Prior Authorization

Cequa (cyclosporine 0.09%) ophthalmic solution

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

Criteria

Cequa

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of keratoconjunctivitis sicca (dry eye)

Cequa

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

2024-05-29, 2024-02-08, 2023-08-22, 2023-02-02, 2022-01-28, 2021-03-03, 2020-03-25, 2020-02-12

References

1. Cequa Prescribing Information. Sun Pharmaceutical Industries, Inc. Cranbury, NJ. March 2021.
2. American Academy of Ophthalmology. Dry Eye Syndrome Preferred Practice Pattern. November 2018. https://www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Accessed January 28, 2022.

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Revision History

• 2024-05-29: update guideline
• 2024-02-08: 2024 Annual Review
• 2023-08-22: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-02-02: 2023 Annual Review
• 2022-01-28: 2022 Annual Review
• 2021-03-03: 2021 Annual Review, removed reference to drug name from reauth criteria.
• 2020-03-25: Updated to remove OTC requirement, updated background references.
• 2020-02-12: Annual Review - Updated References

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