Oxervate — CareFirst (Caremark)

Initial criteria

• Authorization of 16 weeks (8 weeks total therapy per eye) may be granted for treatment of stage 2 and stage 3 neurotrophic keratitis when all of the following criteria are met:
• The member must experience persistent epithelial defects (PED) or corneal ulceration of at least 2 weeks duration refractory to one or more conventional non-surgical treatments (e.g., preservative free artificial tears).
• There is evidence of decreased corneal sensitivity (e.g., cotton swab method, Cochet-Bonnet contact aesthesiometer, CRCERT-Belmonte non-contact aesthesiometer) within the area of the PED or corneal ulcer and outside of the area of the defect in at least one corneal quadrant.
• The member has not received a previous 8-week course of Oxervate in the affected eye.
• This medication must be prescribed by or in consultation with an ophthalmologist or optometrist.

Approval duration

16 weeks (8 weeks total therapy per eye)