Prior Auth Protocol

FDA Approved Indications:

To increase tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca.

Health Net Approved Indications and Usage Guidelines:

Diagnosis of moderate to severe keratoconjunctivitis sicca (chronic dry eye disease (CDED)) confirmed by an ophthalmologist or optometrist

AND

Failure or clinically significant adverse effects to any non-prescription wetting agents in the form of drops, ointments, or gels.

Coverage is Not Authorized For:

Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.

General Information:

Artificial tears are the standard therapy for all severity of dry eyes.
Restasis^R is likely to be given in conjunction with artificial tears.
Increased tear production was not seen in patients currently taking topical anti-inflammatory drugs or using punctal plugs.

Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
Various Products (OTC)	1-2 drops in affected eye(s) TID or QID	N/A

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
Restasis^R	1 drop twice daily in each eye approximately 12 hours apart	Length of benefit For AHCS requests: One Year

Restasis^R

1 drop twice daily in each eye approximately 12 hours apart

Length of benefit

For AHCS requests: One Year

Product Availability:

Single Use vial: 0.05%, 0.4 mL 30 vials/tray and 60 vials/tray

References:

Restasis [Prescibing Information]. Irvine, CA: Allergan; January 2014.
Sall K, Stevenson OD, Mundorf TK, et al for the CsA Phase 3 Study Group. Ophthalmic emulsion in moderate to severe dry eye disease. Ophthalmology 2000;107:631-639.
Restasis, In: DRUGDEX^R System (electronic version). Truven Health Analytics, Greenwood Village, Colorado, USA. Available at: http://www.micromedexsolutions.com/. Accessed June 17, 2015
Restasis. American Hospital Formulary Service Drug Information. Available at: http://www.medicinescomplete.com/mc/ahfs/current/. Accessed June 17, 2015.