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

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

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