Luminopia — Blue Cross Blue Shield of Illinois

Initial criteria

• Diagnosis of amblyopia associated with anisometropia and/or with mild strabismus AND
• Interpupillary distance ≥ 52 mm AND
• Requested digital therapy will be used in combination with full-time refractive correction (e.g., glasses) AND
• If the patient has an FDA labeled indication, then ONE of the following: (A) patient's age is within FDA labeling for the requested indication OR (B) there is support for using the requested agent for the patient's age for the requested indication

Reauthorization criteria

• Patient previously approved for the requested digital therapy device through the plan’s Prior Authorization process AND
• Clinical benefit with the requested digital therapeutic AND
• If the patient has an FDA labeled indication, then ONE of the following: (A) patient's age is within FDA labeling for the requested indication OR (B) there is support for using the requested agent for the patient's age for the requested indication

Approval duration

initial: 3 months or through end of FDA labeled age, whichever shorter; renewal: 12 months or through end of FDA labeled age, whichever shorter