Luminopia — Blue Cross Blue Shield of Texas

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 applies: A. Patient’s age is within FDA labeling for the requested indication 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 applies: A. Patient’s age is within FDA labeling for the requested indication 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)