Xdemvy — Blue Cross Blue Shield of Oklahoma

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: Collarettes (cylindrical dandruff at the eyelash base) OR Lid margin erythema or edema OR Conjunctival injection OR Eyelash misdirection/irregularity AND
• 2. The patient has ONE of the following symptoms of Demodex infestation: Blurred/fluctuating vision OR Discharge or crusting on lashes OR Dryness OR Foreign body sensation OR Itching OR Pain/burning OR Watering/tearing AND
• 3. The patient has ONE of the following (medical records required): The patient is currently being treated with the requested agent and is stable on it OR Tried tea tree oil eyelid scrubs for at least 6 weeks with inadequate response OR Discontinued tea tree oil eyelid scrubs due to lack of efficacy/effectiveness, diminished effect, or adverse event OR Has intolerance or hypersensitivity to tea tree oil eyelid scrubs OR Has an FDA labeled contraindication to tea tree oil eyelid scrubs OR Tea tree oil eyelid scrubs expected to be ineffective or cause harm or barrier to care or worsen comorbid condition or decrease functional ability OR Tea tree oil eyelid scrubs are not in the best interest of the patient based on medical necessity OR Tried another prescription drug in same pharmacologic class or with same mechanism of action as tea tree oil eyelid scrubs and it was 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 supported in compendia for 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 the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
• 3. The patient does NOT have any FDA labeled contraindications to the requested agent.

Approval duration

2-12 months (plan dependent: BCBSIL 12 months; BCBSMT/BCBSNM 3 months; others 2 months)