Xdemvy — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years; AND
• Patient has a diagnosis of Demodex blepharitis; AND
• Diagnosis has been verified by the presence of collarettes on more than 10 lashes on the upper lid and presence of at least mild erythema on the upper eyelid margin [documentation required]; AND
• Patient has moderate to severe blepharitis symptoms that interfere with daily life; AND
• Patient’s symptoms persist despite treatment with warm compress, eyelid cleansing, and/or artificial tears; AND
• Xdemvy is prescribed by or in consultation with an optometrist or ophthalmologist

Approval duration

45 days