Restasis (cyclosporine ophthalmic 0.05%) Letter of Medical Necessity
Restasis (cyclosporine ophthalmic) PA typically requires documented failure of artificial tears and objective dry eye disease severity measures.
FDA-Approved Indications
- ● chronic dry eye disease secondary to keratoconjunctivitis sicca
Why Restasis Prior Authorization Gets Denied
The most common denial reasons across major payers:
- 1. Artificial tears trial not documented
- 2. Generic cyclosporine ophthalmic preferred
- 3. Schirmer score missing
What to Include in a Restasis Letter of Medical Necessity
Document dry eye diagnosis, OSDI score, Schirmer test results, prior artificial tears trial duration and outcome, and ocular surface findings.
Key clinical evidence to cite:
- ✓ Pivotal trials demonstrating tear production improvement
Relevant guidelines:
- 📖 AAO Dry Eye Preferred Practice Pattern
Restasis Prior Authorization Criteria
Standard criteria across major US payers for Restasis. Specific criteria vary by plan — RxCheckUp tailors each LMN to your patient's exact payer policy.
Typical step therapy requirements:
- → Artificial tears trial not documented
Required documentation:
- ✓ ICD-10 diagnosis code with specificity
- ✓ Prior therapy history with dates, doses, and discontinuation reasons
- ✓ Specialist evaluation (where applicable)
- ✓ Baseline disease activity or biomarker results
- ✓ Clinical rationale citing FDA labeling or guidelines
Approval details:
Initial approval: typically 6 months. Renewal: 12 months with documented clinical response.
Payers Covering Restasis
RxCheckUp tailors each LMN to the specific payer's medical policy and step therapy requirements:
Restasis Prior Authorization FAQ
Why was my Restasis prior authorization denied?
The most common denial reasons for Restasis are: Artificial tears trial not documented; Generic cyclosporine ophthalmic preferred; Schirmer score missing.
What should a Restasis Letter of Medical Necessity include?
Document dry eye diagnosis, OSDI score, Schirmer test results, prior artificial tears trial duration and outcome, and ocular surface findings.
Which payers cover Restasis?
Restasis is covered by major US payers including UnitedHealthcare, Aetna, Cigna, CVS Caremark, Medicare Part D, though formulary tier and prior authorization criteria vary.