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

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): The patient is currently being treated with and stable on the requested agent OR tried tea tree oil eyelid scrubs ≥ 6 weeks with inadequate response OR discontinued due to lack of efficacy/diminished effect/adverse event OR intolerance/hypersensitivity OR FDA contraindication OR expected to be ineffective or cause adherence/comorbidity/function issues/adverse reaction OR not in patient’s best interest OR tried another prescription drug in the same pharmacologic class or mechanism as tea tree oil eyelid scrubs and discontinued due to lack of efficacy/effectiveness/diminished effect/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 (e.g., ophthalmologist or optometrist) or has consulted with one;
• AND The patient does NOT have any FDA labeled contraindications to the requested agent.

Approval duration

3 months (BCBSMT)