Xdemvy (lotilaner) ophthalmic solution 0.25% — United Healthcare

Demodex blepharitis

Initial criteria

Diagnosis of Demodex blepharitis
AND Patient demonstrates one of the following signs of Demodex infestation: cylindrical cuff at the root of the eyelashes OR lid margin erythema OR eyelash anomalies (eyelash misdirection)
AND Patient demonstrates two of the following symptoms of Demodex infestation: itching/burning OR foreign body sensation OR crusting/matter lashes OR blurry vision OR discomfort/irritation
AND Patient is practicing good eye-lid hygiene (e.g., non-prescription tree-tea oil)
AND Prescribed by or in consultation with an Ophthalmologist OR Optometrist

3 months