requested agent — Blue Cross Blue Shield of Kansas

Initial criteria

• Patient has persistent epithelial defect (PED) or corneal ulcer persisting for at least 2 weeks despite conventional non-surgical treatments for NK (e.g., preservative-free artificial tears or ointment, discontinuation of preserved topical agents that can decrease corneal sensitivity, therapeutic soft contact lenses, topical autologous serum application, botulinum A toxin treatment) OR patient has intolerance or hypersensitivity to at least one conventional non-surgical treatment for NK OR patient has an 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 had complete corneal healing in the previously treated eye(s) AND has a recurrence of NK requiring another treatment course (medical records required)
• ONE of the following: the patient does not have ocular surface disease associated with or in conjunction with NK OR patient has ocular surface disease associated with or in conjunction with NK AND the ocular surface disease has been properly treated
• Patient will NOT be using the requested agent in combination with a topical ophthalmic NSAID
• Patient does NOT have active ocular infection or active ocular inflammation not related to NK in the affected eye, severe blepharitis or severe Meibomian gland disease in the affected eye, history of ocular surgery in the affected eye within the past 90 days that has not been determined to be the cause of NK, corneal perforation, ulceration involving the posterior third of the corneal stroma, or corneal melting
• Prescriber is a specialist in optometry/ophthalmology or has consulted with one regarding the diagnosis
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

16 weeks