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

Initial criteria

• For BCBS MT Fully Insured or MT HIM member: The patient is under age 18 years; The patient has no FDA labeled contraindications; The indication is supported in two peer-reviewed journal articles as generally safe and effective; There is support for the patient’s age bracket in two peer-reviewed journal articles as generally safe and effective
• OR For Ohio residents with Fully Insured or HIM Shop (SG) plan: The patient has no FDA labeled contraindications AND ONE of the following: The patient has another FDA labeled indication for the requested agent and route of administration OR The patient has another indication supported in compendia for the requested agent and route of administration OR The prescriber has submitted two peer-reviewed journal articles supporting proposed use as safe and effective per accepted study designs
• Allowable compendia: DrugDex level 1, 2A, or 2B; AHFS-DI supportive narrative; NCCN 1 or 2A; Clinical Pharmacology supportive narrative; LexiDrugs evidence level A; or peer-reviewed medical literature

Approval duration

12 months