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

other FDA labeled indication for Xdemvy

Initial criteria

For Ohio residents with Fully Insured or HIM Shop (SG) plans:
1. The member resides in Ohio AND
2. The plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
B. ONE of the following:
1. The patient has another FDA labeled indication for the requested agent and route of administration OR
2. The patient has another indication that is supported in compendia for the requested agent and route of administration OR
3. The prescriber has submitted TWO articles from major peer‑reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective. Accepted study designs may include randomized, double‑blind, placebo‑controlled clinical trials (case studies not acceptable).
Non‑oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS‑DI (narrative text supportive).
Oncology compendia allowed: NCCN 1 or 2A, AHFS‑DI (narrative text supportive), DrugDex level 1, 2A or 2B, Clinical Pharmacology (narrative text supportive), LexiDrugs evidence level A, peer‑reviewed medical literature.

12 months