SAVINGS: PRIOR AUTHORIZATION, BILLING & CODING

Helpful information for your office

To submit a Prior Authorization, your office may need this information

In the event a Prior Authorization is necessary, give a brief summary of the rationale for treatment with CEQUATM, including:

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A description of the diagnosis, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code, severity of the patient’s condition, symptoms, and age

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Previous therapies such as over-the-counter and prescription medications, reasons for discontinuation, and duration of therapy

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Clinical support for the appeal

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Evidence for your recommendation

Relevant codes when billing and coding for CEQUA

The following is an overview of current relevant codes that may be potential options for use with CEQUA:
ICD-10-CM Description
H16.223 Keratoconjunctivitis sicca, not specified as Sjögren’s, bilateral
H04.121 Dry eye syndrome of the right lacrimal gland
H04.122 Dry eye syndrome of the left lacrimal gland
H04.123 Dry eye syndrome of the bilateral lacrimal glands
H04.129 Dry eye syndrome of unspecified lacrimal gland

CEQUA is indicated for use in patients with keratoconjunctivitis sicca1

Indications and Usage

CEQUATM (cyclosporine ophthalmic solution) 0.09% is a calcineurin inhibitor immunosuppressant indicated to increase tear production in patients with keratoconjunctivitis sicca (dry eye).

Important Safety Information

Warnings and Precautions

Potential for Eye Injury and Contamination: To avoid the potential for eye injury and contamination, advise patients not to touch the vial tip to the eye or other surfaces.

Use with Contact Lenses: CEQUA should not be administered while wearing contact lenses. If contact lenses are worn, they should be removed prior to administration of the solution. Lenses may be reinserted 15 minutes following administration of CEQUA ophthalmic solution.

Adverse Reactions

The most common adverse reactions reported in greater than 5% of patients were pain on instillation of drops (22%) and conjunctival hyperemia (6%). Other adverse reactions reported in 1% to 5% of patients were blepharitis, eye irritation, headache, and urinary tract infection.

Please see the Full Prescribing Information.

Indications and Usage

CEQUATM (cyclosporine ophthalmic solution) 0.09% is a calcineurin inhibitor immunosuppressant indicated to increase tear production in patients with keratoconjunctivitis sicca (dry eye).

Important Safety Information

Warnings and Precautions

Potential for Eye Injury and Contamination: To avoid the potential for eye injury and contamination, advise patients not to touch the vial tip to the eye or other surfaces.

Use with Contact Lenses: CEQUA should not be administered while wearing contact lenses. If contact lenses are worn, they should be removed prior to administration of the solution. Lenses may be reinserted 15 minutes following administration of CEQUA ophthalmic solution.

Adverse Reactions

The most common adverse reactions reported in greater than 5% of patients were pain on instillation of drops (22%) and conjunctival hyperemia (6%). Other adverse reactions reported in 1% to 5% of patients were blepharitis, eye irritation, headache, and urinary tract infection.

Please see the Full Prescribing Information.

Reference: 1. CEQUA [package insert]. Cranbury, NJ: Sun Pharmaceutical Industries, Inc.; 2019.