Luminopia — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Diagnosis of amblyopia associated with anisometropia and/or with mild strabismus
• Interpupillary distance ≥ 52 mm
• 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) 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

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