Oxervate (cenegermin-bkbj) — Blue Cross Blue Shield of Alabama

Initial criteria

• - Diagnosis of neurotrophic keratitis (NK)
• - Stage 2 (persistent epithelial defect [PED]) or stage 3 (corneal ulcer) NK
• - ONE of the following:
• • Patient has NOT been previously treated with the requested agent in the affected eye(s) AND ALL of the following:
• - PED and/or corneal ulcer present for at least 2 weeks
• - ONE of the following:
• • NK refractory to at least ONE conventional non-surgical treatment (e.g., preservative-free lubricant eye drops or ointment, discontinuation of preserved topical agents that can decrease corneal sensitivity, therapeutic soft contact lenses, topical autologous serum application, botulinum A toxin treatment)
• • Intolerance or hypersensitivity to at least ONE conventional non-surgical treatment for NK
• • FDA labeled contraindication to ALL conventional non-surgical treatments for NK
• - Patient has decreased corneal sensitivity within the area of the PED or ulcer and outside the area of defect in at least one corneal quadrant
• • OR patient has been previously treated with the requested agent in the affected eye(s) AND BOTH of the following:
• - Complete corneal healing in the previously treated eye(s) (medical records required)
• - Recurrence of NK requiring another treatment course (medical records required)
• - ONE of the following:
• • Patient does NOT have ocular surface disease associated with or in conjunction with NK
• • BOTH of the following (if surface disease present) – not fully listed but implied from continuation