Xiidra
Drug - Xiidra™ (lifitegrast ophthalmic solution) [Shire]
January 2017
Therapeutic area - Eye Conditions
Initial criteria
- Patient is 17 years of age or older AND
- Has a diagnosis of chronic dry eye disease (DED) AND
- Has presence of conjunctival redness AND
- Must have one of the following signs of DED
- Corneal fluoresceine staining score of ≥ 2 points in any field on a 0 to 4 point scale OR
- Schirmer tear test (STT) of 1 to 10mm in 5 minutes AND
- Patient should NOT be using concurrent Restasis
- Patient has had adequate trial (at least 3 months) and failure of over-the-counter (OTC) artificial tears (used at least 4 times daily) as documented in pharmacy fill history or chart notes indicating fill/refill history if patient is new to Medical Assistance and pharmacy claims data is not readily available
Renewal criteria
- Patient must have documented improvement in signs of DED as measured by at least ONE of the following:
- Decrease in corneal fluoresceine staining score OR
- Increase in number of mm per 5 minutes using Schirmer tear test AND
- Patient must have documented decrease in conjunctival redness AND
- Patient must have documented improvement in ocular discomfort AND
- Patient should NOT be using concurrent Restasis
Quantity limits
- 60 single-use containers per 30 days
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411