Prior Auth Protocol

Prior Authorization Protocol

XIIDRA (lifitegrast ophthalmic solution)

NATL

Interim Guidelines; Final Review and Approval by the P&T Committee Pending

Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.

FDA Approved Indications:
- For the treatment of signs and symptoms of dry eye disease.
Health Net Approved Indications and Usage Guidelines:
- Diagnosis of dry eye disease (DED)
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.
- One single-use container can be used to dose both eyes, per the Xiidra prescribing information.
Therapeutic Alternatives:

Drug Dosing Regimen Dose Limit/ Maximum Dose
Various OTC products
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
Xiidra
1 drop BID OU
Length of benefit
Product Availability:

Single Use vial: 5% (50 mg/mL), 0.2 mL carton of 60 single-use containers
References:
1. Xiidra [Prescibing Information]. Lexington, MA, Shire US Inc.; June 2016.
2. Micromedex. Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed September 2016

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

Drug	Dosing Regimen	Authorization Limit
Xiidra	1 drop BID OU	Length of benefit

The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.