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Oxervate — Blue Cross Blue Shield of Illinois

stage 2 (persistent epithelial defect) NK

Initial criteria

  • Diagnosis of neurotrophic keratitis (NK)
  • Stage 2 (persistent epithelial defect) or stage 3 (corneal ulcer) NK
  • ONE of the following:
  • A. Patient has NOT been previously treated with the requested agent in the affected eye(s) AND ALL of the following:
  • 1. PED or corneal ulcer present for ≥ 2 weeks AND
  • 2. ONE of the following:
  • A. BOTH of the following:
  • 1. Patient has stage 4 advanced, metastatic cancer and the requested agent is used to treat the cancer or associated condition; and
  • 2. Use consistent with best practices and FDA-approved, peer-reviewed literature OR
  • B. NK refractory to at least ONE conventional non-surgical treatment (preservative-free lubricant eye drops or ointment, discontinuation of preserved topical agents, therapeutic soft contact lenses, topical autologous serum, botulinum A toxin) OR
  • C. Intolerance or hypersensitivity to at least ONE conventional non-surgical treatment for NK OR
  • D. FDA labeled contraindication to ALL conventional non-surgical treatments for NK AND
  • 3. 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
  • B. Patient has been previously treated with the requested agent in affected eye(s) AND BOTH of the following:
  • 1. Patient had complete corneal healing in previously treated eye(s) (medical records required) AND
  • 2. Recurrence of neurotrophic keratitis requiring another treatment course (medical records required)
  • ONE of the following regarding ocular surface disease:
  • A. No ocular surface disease associated with NK OR
  • B. If ocular surface disease present, it has been properly treated
  • Patient will NOT use requested agent in combination with a topical ophthalmic NSAID
  • Patient does NOT have any of the following in affected eye: active ocular infection or inflammation not related to NK, severe blepharitis/Meibomian gland disease, ocular surgery within past 90 days that caused NK, corneal perforation, ulceration involving posterior third of stroma, or corneal melting
  • Prescriber is a specialist (optometrist, ophthalmologist) or has consulted with one
  • Patient does NOT have FDA labeled contraindications to the requested agent

Approval duration

BCBSIL & BCBSMT: 6 months; Others: 16 weeks