Xdemvy (lotilaner) — Highmark

Initial criteria

• age ≥ 18 years
• Diagnosis of Demodex blepharitis confirmed by ONE of the following: (1) identification of Demodex infestation via microscopic examination of pulled eyelashes OR (2) identification of collarettes via slit-lamp evaluation
• Member is experiencing at least one symptom of blepharitis associated with Demodex infestation (e.g., erythema, inflammation, itching, burning, tearing, foreign body sensation, blurred vision)

Reauthorization criteria

• Diagnosis of Demodex blepharitis confirmed by ONE of the following: (1) identification of Demodex infestation via microscopic examination of pulled eyelashes OR (2) identification of collarettes via slit-lamp evaluation
• Member is experiencing at least one symptom of blepharitis associated with Demodex infestation (e.g., erythema, inflammation, itching, burning, tearing, foreign body sensation, blurred vision)
• Member has not received a treatment course of Xdemvy within the previous 180 days
• Prescriber attests that the member requires retreatment with Xdemvy

Approval duration

6 weeks