Tyrvaya™

Drug - Tyrvaya™ (varenicline nasal spray) [Oyster Point Pharma]

October 2022

Therapeutic area - Ophthalmics, Anti-Inflammatory/Immunomodulator

Initial approval criteria

Patient is at least18 years old AND
Patient has diagnosis of dry eye disease (DED) AND
Prescribed by or in consultation with an ophthalmologist or optometrist AND
Prescriber attestation that causative factors cannot be mitigated AND
Patient has had adequate trial (at least 3 months) and failure of over-the-counter (OTC) artificial tears 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 AND
Patient has had a 3-month trial and failure of (or contraindication) to Restasis, cyclosporine 0.09% ophthalmic solution or cyclosporine 0.05% ophthalmic emulsion AND
Prescriber has documented at least one of the following signs of DED:
- Corneal fluorescein staining (CFS) score of ≥ 2 points in any field on a 0 to 4 point scale OR
- Schirmer tear test (STT) of 1 to 10 mm in 5 minutes

Patient continues to meet the above criteria AND
Patient has not had treatment-limiting adverse effects from the drug (e.g., excessive sneezing, cough, throat irritation, instillation-site irritation) AND
Patient has improvement in signs of DED, as measured by at least one of the following:
- Decrease in corneal fluorescein staining score OR
- Increase in number of mm per 5 minutes using Schirmer tear test

MHCP Provider Resource Center 651-431-2700 or 800-366-5411