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L.5.01.445
Lacrisert (hydroxypropyl cellulose
insert
)
Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
Lacrisert (hydroxypropyl cellulose insert) is indicated in patients with moderate to severe dry eye syndromes, including keratoconjunctivitis sicca. Lacrisert (hydroxypropyl cellulose insert) is indicated especially in patients who remain symptomatic after an adequate trial of therapy with artificial tear solutions. Lacrisert (hydroxypropyl cellulose insert) is also indicated for patients with exposure keratitis, decreased corneal sensitivity, and recurrent corneal erosions.
Prior Authorization is required.
The use of samples by an individual will not be considered current or stable therapy to satisfy Medical Policy requirements.
Lacrisert (hydroxypropyl cellulose insert) may be considered medically necessary when ALL of the following criteria are met:
ONE of the following:
BOTH
of the following:
The individual has a diagnosis of keratoconjunctivitis sicca or KCS (dry eye disease) AND
The individual remains symptomatic after an adequate trial (3 months or more) of an artificial tear solution;
The individual has a diagnosis of exposure keratitis;
The individual has decreased corneal sensitivity; OR
The individual has recurrent corneal erosions.
State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
01/01/2014: New policy added.
07/31/2015: Code Reference section updated for ICD-10.
05/27/2016: Policy number L.5.01.445 added. Investigative definition updated in Policy Guidelines.
06/13/2016: Approved by Pharmacy & Therapeutics (P&T) Committee.
05/16/2017: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee.
03/27/2018: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee.
07/01/2018: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Added drug names to the top of the policy. Policy description updated to state that Lacrisert (hydroxypropyl cellulose pellet) is FDA-approved for use in patients with moderate to severe dry eye syndromes, including keratoconjunctivitis sicca, exposure keratitis, decreased corneal sensitivity, and recurrent corneal erosions. Policy statements unchanged.
10/01/2019: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Policy description updated to add indications for Lacrisert. Policy section updated to add that prior authorization is required and that the use of samples by a Member will not be considered current or stable therapy for purposes of Medical Policy review. Policy statement criteria updated to state that the patient remains symptomatic after an adequate trial (3 months or more) of an artificial tear solution. Policy Exceptions updated to remove statement regarding FEP and State Health Plan members. Source updated.
02/01/2023: Policy Exceptions updated to add the following: State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.
06/03/2025: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy title, policy description, and policy statement updated to change "Lacrisert (hydroxypropyl cellulose pellet)" to "Lacrisert (hydroxypropyl cellulose insert)." Policy statement revised to state that the use of samples by an individual will not be considered current or stable therapy to satisfy Medical Policy requirements. Policy statement criteria updated to change "patient" to "individual." Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Sources updated.
Lacrisert prescribing information. Bausch & Lomb Incorporated. July 2024. Last accessed March 2025.
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