Oxervate (cenegermin-bkbj ophth soln 0.002%) — Blue Cross Blue Shield of Montana

Initial criteria

• Quantity Limit will be approved when ONE of the following is met:
• 1. The requested quantity does NOT exceed the program quantity limit OR
• 2. The requested quantity exceeds the program quantity limit AND BOTH of the following: The patient has bilateral neurotrophic keratitis (NK) AND The requested quantity does NOT exceed TWICE the program quantity limit

Approval duration

12 months (BCBSIL); 16 weeks (other plans)