Medicare AdvantagePrior AuthMedium impact
Ophthalmic Cyclosporine (Cequa®, Restasis®, Restasis MultiDose®, Vevye®) (Revised)
Humana·Ophthalmology, Optometry, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jul 2, 2026
Summary
Humana Medicare Advantage now requires prior authorization for ophthalmic cyclosporine products (Cequa, Restasis, Restasis MultiDose, Vevye) for dry eye disease treatment. Coverage requires members to have a diagnosis of DED AND prior treatment/contraindication/intolerance to generic Restasis AND concurrent use of Eysuvis, Miebo, or Tryptyr. This is a restrictive coverage policy requiring prior auth before dispensing.
Action Required
By January 1, 2025: Billing and pharmacy teams must implement prior authorization requirement for all ophthalmic cyclosporine products (Cequa, Restasis, Restasis MultiDose, Vevye) for Humana Medicare Advantage members. Update pharmacy billing system to flag these medications as requiring prior auth before dispensing. Verify that member meets ALL criteria: (1) documented dry eye disease diagnosis, (2) prior treatment/contraindication/intolerance to generic Restasis, AND (3) concurrent prescription for Eysuvis, Miebo, or Tryptyr. Communicate new requirements to prescribing ophthalmologists and optometrists in network. Claims submitted without prior authorization documentation will be denied by Humana.