Skip to content
The Policy VaultThe Policy Vault

lotilaner ophthalmic solution 0.25% — Blue Cross Blue Shield of Illinois

Demodex blepharitis

Initial criteria

  • ONE of the following:
  • A. The patient has a diagnosis of Demodex blepharitis AND ALL of the following:
  • 1. The patient has ONE of the following signs of Demodex infestation: Collarettes (cylindrical dandruff at the eyelash base) OR Lid margin erythema or edema OR Conjunctival injection OR Eyelash misdirection/irregularity AND
  • 2. The patient has ONE of the following symptoms of Demodex infestation: Blurred/fluctuating vision OR Discharge or crusting on lashes OR Dryness OR Foreign body sensation OR Itching OR Pain/burning OR Watering/tearing AND
  • 3. The patient has ONE of the following (medical records required):
  • A. The patient is currently being treated with the requested agent and is stable OR
  • B. The patient has tried tea tree oil eyelid scrubs for at least 6 weeks and had an inadequate response OR
  • C. Tea tree oil eyelid scrubs were discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event OR
  • D. The patient has an intolerance or hypersensitivity to tea tree oil eyelid scrubs OR
  • E. The patient has an FDA labeled contraindication to tea tree oil eyelid scrubs OR
  • F. Tea tree oil eyelid scrubs are expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the drug; OR cause a significant barrier to adherence; OR worsen a comorbid condition; OR decrease functional ability in performing daily activities; OR cause an adverse reaction or physical/mental harm OR
  • G. Tea tree oil eyelid scrubs are not in the best interest of the patient based on medical necessity OR
  • H. The patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action as tea tree oil eyelid scrubs and that prescription drug was discontinued due to lack of efficacy, diminished effect, or adverse event OR
  • B. The patient has another FDA labeled indication for the requested agent and route of administration OR
  • C. The patient has another indication supported in compendia for the requested agent and route of administration AND
  • The prescriber is a specialist in ophthalmology or optometry or has consulted with a specialist AND
  • The patient does not have any FDA labeled contraindications to the requested agent

Approval duration

12 months (BCBSIL); 3 months (BCBSMT, BCBSNM); 2 months (all other plans)