Luminopia — Blue Cross Blue Shield of Montana

Initial criteria

• The patient has a diagnosis of amblyopia associated with anisometropia and/or with mild strabismus
• The patient has an interpupillary distance of at least 52 mm
• The patient will use the requested digital therapy in combination with full-time refractive correction (e.g., glasses)
• If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) There is support for using the requested agent for the patient’s age for the requested indication

Reauthorization criteria

• The patient has been previously approved for the requested digital therapy device through the plan’s Prior Authorization process
• The patient has had clinical benefit with the requested digital therapeutic
• If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication for the requested agent 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