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lotilaner ophthalmic solution 0.25% — Blue Cross Blue Shield of New Mexico

Demodex blepharitis

Initial criteria

  • 1. 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. Currently treated and stable on the requested agent OR B. Tried tea tree oil eyelid scrubs ≥6 weeks with inadequate response OR C. Tea tree oil eyelid scrubs discontinued due to lack of efficacy/effectiveness, diminished effect, or adverse event OR D. Intolerance or hypersensitivity to tea tree oil eyelid scrubs OR E. FDA labeled contraindication to tea tree oil eyelid scrubs OR F. Tea tree oil eyelid scrubs expected to be ineffective or cause barrier/adverse effect/worsen comorbidity/decrease function OR G. Tea tree oil eyelid scrubs not in best interest of patient based on medical necessity OR H. Tried another prescription drug in same pharmacologic class or with same mechanism of action as tea tree oil eyelid scrubs and discontinued due to lack of efficacy/effectiveness, diminished effect, or adverse event
  • 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
  • 2. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., ophthalmologist, optometrist), or has consulted with a specialist AND
  • 3. The patient does NOT have any FDA labeled contraindications to the requested agent.
  • Compendia Allowed: AHFS, DrugDex level 1, 2A, or 2B.

Approval duration

3 months (BCBSNM plans)