Xdemvy — Blue Cross Blue Shield of Kansas

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:
A. Collarettes (cylindrical dandruff at the eyelash base) OR
B. Lid margin erythema or edema OR
C. Conjunctival injection OR
D. Eyelash misdirection/irregularity AND
2. The patient has ONE of the following symptoms of Demodex infestation:
A. Blurred/fluctuating vision OR
B. Discharge or crusting on lashes OR
C. Dryness OR
D. Foreign body sensation OR
E. Itching OR
F. Pain/burning OR
G. Watering/tearing AND
3. The patient has ONE of the following (medical records required):
A. Tried tea tree oil eyelid scrubs for at least 6 weeks and had an inadequate response OR
B. An intolerance or hypersensitivity to tea tree oil eyelid scrubs OR
B. The patient has another FDA labeled indication for the requested agent and route of administration OR
C. The patient has another indication that is supported in compendia for the requested agent and route of administration AND
The prescriber is a specialist in the area of the patient’s diagnosis (e.g., ophthalmologist, optometrist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
The patient does NOT have any FDA labeled contraindications to the requested agent

2 months