Oxervate — Medical Mutual

Initial criteria

• Oxervate is prescribed by or in consultation with an ophthalmologist; AND
• The patient has been diagnosed with stage 2 or stage 3 Neurotrophic Keratitis as evidenced by the presence of persistent epithelial defect (PED) or corneal ulcer; AND
• The patient has failed an adequate trial of at least one over-the-counter (OTC) ocular artificial tears product (e.g., Refresh Optive, Systane Ultra, Akwa Tears, etc.)

Approval duration

2 months