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Oxervate (cenegermin-bkbj) — Blue Cross Blue Shield of Texas

neurotrophic keratitis (NK)

Initial criteria

  • Diagnosis of neurotrophic keratitis (NK)
  • Patient has stage 2 (persistent epithelial defect [PED]) or stage 3 (corneal ulcer) NK
  • ONE of the following:
  • A. Patient has NOT been previously treated with the requested agent in the affected eye(s) AND ALL of:
  • 1. PED and/or corneal ulcer present ≥ 2 weeks
  • 2. ONE of the following:
  • A. BOTH of: (1) Patient has been diagnosed with stage four advanced, metastatic cancer and requested agent is being used to treat the cancer OR a related condition; (2) Use is consistent with best practices, supported by peer-reviewed evidence, and FDA approved OR
  • B. NK refractory to ≥ 1 conventional non-surgical treatment (such as preservative-free lubricant eye drops/ointment, discontinuation of preserved topical agents, therapeutic soft contact lenses, topical autologous serum, botulinum A toxin) OR
  • C. Intolerance or hypersensitivity to ≥ 1 conventional non-surgical treatment for NK OR
  • D. FDA labeled contraindication to ALL conventional non-surgical NK treatments AND
  • Patient has decreased corneal sensitivity within or outside the defect in ≥ 1 corneal quadrant
  • OR
  • B. Patient previously treated with requested agent in affected eye(s) AND BOTH of:
  • 1. Complete corneal healing in previously treated eye(s) (medical records required)
  • 2. Recurrence of NK requiring another treatment course (medical records required)
  • AND
  • ONE of the following:
  • A. No ocular surface disease associated with NK OR
  • B. BOTH of ocular surface disease present and properly treated
  • AND
  • Patient will not be using requested agent in combination with topical ophthalmic NSAID
  • AND
  • Patient does not have any of the following: (a) active ocular infection/inflammation unrelated to NK; (b) severe blepharitis/Meibomian gland disease; (c) recent ocular surgery within past 90 days causing NK; (d) corneal perforation, deep ulcer, or corneal melting
  • AND
  • Prescriber is a specialist (optometrist, ophthalmologist) or has consulted one
  • AND
  • Patient does not have any FDA labeled contraindications to requested agent

Approval duration

6 months (BCBSIL, BCBSMT) or 16 weeks (others)