EYSUVIS (loteprednol etabonate)

EYSUVIS (loteprednol etabonate) 

SELF ADMINISTRATION - OPHTHALMIC SUSPENSION

Indication for Prior Authorization:

• Indicated for the short-term (up to two weeks) treatment of the signs and symptoms of dry eye disease

Coverage Criteria:

• Patient has a diagnosis of dry eye disease, AND
• Prescribed by or in consultation with an optometrist or ophthalmologist, AND
• Patient has tried and failed artificial tears as confirmed by chart note documentation, AND
• Patient has tried and failed loteprednol 0.5% suspension OR fluorometholone 0.1% suspension for at least 14 days

Dosing:

• One to two drops into each eye four times daily for up to two weeks

Coverage Duration:

• 1 fill (limited to quantity 8.3mL per 6 months)

Authorization is Not Covered for the Following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics Committee.

Additional Information:

• Contraindications:
  • Most viral diseases of the cornea and conjunctiva including epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, and varicella
  • Mycobacterial infection of the eye and fungal diseases of ocular structures
• Additional warnings for: delayed healing and corneal perforation, Intraocular Pressure (IOP) increase, cataract, bacterial infections, viral infections, fungal infections, risk of contamination, and preservative in Eysuvis may be absorbed by soft contact lenses

Review History:

• 4/20/21- Original review

References:

• Eysuvis prescribing information. Kala Pharmaceuticals, Inc. Watertown, MA. November 2020.
• Per clinical consult with an ophthalmologist, December 21, 2020.
• Shtein, RM. Dry eye disease. In: Post T, ed. UpToDate. UpToDate; 2020. Accessed December 16, 2020. www.uptodate.com
• Micromedex Healthcare Series [database on the Internet]. Greenwood Village (CO): IBM Corporation.; Updated periodically. Available by subscription at: https://www.micromedexsolutions.com/. Accessed December 16, 2020.