CEQUA (cyclosporine)

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