Vevye™

Drug - Vevye™ (cyclosporine) [Harrow Eye, LLC.]

January 2025

Therapeutic area - Ophthalmics, Anti-Inflammatory/Immunomodulators

Initial approval criteria

Patient must be at least 18 years old AND
Has a diagnosis of dry eye disease (DED) 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 has trialed and failed, or has a contraindication to Restasis or its generic equivalent AND
Patient must not have current use of any of the following:
- Another ophthalmic cyclosporine product (e.g., Cequa, Restatis) OR
- Miebo OR
- Tyrvaya OR
- Xiidra

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 not have current use of any of the following:
- Another ophthalmic cyclosporine product (e.g., Cequa, Restatis) OR
- Miebo OR
- Tyrvaya OR
- Xiidra

1 bottle per 50 days
Requested quantity (in mL and number of bottles) and the corresponding days supplied must be clearly stated on the prior authorization request form

Provider Call Center (844) 575-7887