Category Filter
- Advanced Imaging
- Behavioral Health
- Chronic Condition Management
- Genetic Testing
- Hemophilia Drugs
- Medical Oncology Regimen Program
- Medical Policies
- Pre-Service Review (Precertification/Predetermination)
- Provider-Administered Drug Policies
- Radiation Therapy
- Self-Administered Drug Policies
- Transgender Services
Asset Publisher
Neurotrophic Keratitis Prior Authorization with Quantity Limit Program Summary
Policy Number: PH-1104
This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
10-01-2024 |
|
FDA LABELED INDICATIONS AND DOSAGE
Agent(s) |
FDA Indication(s) |
Notes |
Ref# |
Oxervate® |
Treatment of neurotrophic keratitis |
|
1 |
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
CLINICAL RATIONALE
Neurotrophic Keratitis |
Neurotrophic keratitis (NK) is a rare corneal degenerative disease that is characterized by a reduction or absence of corneal sensitivity, due to impaired innervation by the trigeminal nerve. The lack of innervation leads to corneal epithelial breakdown, impairment of healing, and development of corneal ulceration, melting, and perforation.(2,3) There are numerous underlying ocular and systemic conditions associated with NK, with the most common causes including herpetic keratitis (zoster and simplex), topical anesthetic abuse, chemical and thermal burns, contact lends abuse, and topical drug toxicity. Corneal procedures have been linked to NK such as LASIK, corneal transplantation surgery, and specifically penetrating keratoplasty (PK) as well as non-corneal ocular surgeries (vitrectomy for retinal detachment and photocoagulation to treat diabetic retinopathy). Additional non-ocular or systemic causes include neurosurgical procedures or trauma damaging the fifth cranial nerve, stroke, aneurysms, multiple sclerosis, intracranial masses, diabetes, leprosy, vitamin A deficiency, and drugs (e.g., narcoleptics, antipsychotics).(2) Diagnosing NK requires clinical ocular and systemic history, complete eye examination, and assessment of corneal sensitivity. The hallmark of NK is a decrease or absence of corneal sensation.(2,3) Corneal sensitivity testing is recommended using a cotton swab, the Cochet-Bonnet contact esthesiometer, or the CRCERT-Belmonte non-contact esthesiometer. If sensitivity testing indicates reduced sensitivity, then corneal staining, Schirmer testing, microbiology exams, lid evaluation, nerve imaging, and limbal evaluation are recommended to determine disease staging and determine underlying etiology.(3) The clinical classification of NK is broken down into three stages. Stage 1 is characterized by corneal epithelial changes with dry and cloudy epithelium, the presence of superficial punctate keratopathy, and corneal edema. Stage 2 is characterized by recurrent and/or PED with an oval or circular shape, mostly localized at the superior half of the cornea. Stage 3 is characterized by corneal ulcer with stromal involvement that may be complicated by stromal melting and progression to corneal perforation.(2) Management of NK aims to promote corneal healing and avoid complications. Patients with NK should use preservative-free medications, as epithelial drug toxicity can complicate the disease. All ocular surface-associated diseases (i.e., dry eye, blepharitis, exposure keratopathy, limbal stem cell deficiency) should be treated. Topical NSAIDs should be avoided in NK as they do not show any benefit and they can decrease corneal sensitivity. Treatment options are determined based on staging. Stage 1 is treated with preservative-free artificial tears and lubricant ointments. Therapeutic soft contact lenses, punctal plugs, and autologous serum could also be options in some cases. Oxervate can be considered in patients that fail to respond to these therapies. Stage 2 treatment includes continuing preservative-free artificial tears and lubricant ointments with prophylactic antibiotic drops. Additional treatment options for stage 2 are therapeutic soft contact lenses, topical autologous serum application, amniotic membrane grafting, conjunctival flap, tarsorrhaphy or botulinum induced ptosis, and topical nerve growth factor application. Treatment for stage 3 includes all of the treatments for stage 1 and 2 with the addition of N-acetylcysteine, oral tetracycline, and medroxyprogesterone can be prescribed in case of stromal melting. Surgical treatments are typically reserved for refractory cases.(2,3) Corneal perforations require immediate treatment with either cyanoacrylate glue and soft bandage contact lenses, or amniotic membrane grafting. Tectonic perforating or lamellar keratoplasty can be performed for larger perforations.(3) |
Efficacy |
Cenegermin ophthalmic solution contains cenegermin, a recombinant form of human nerve growth factor produced in Escherichia coli. Nerve growth factor is an endogenous protein involved in the differentiation and maintenance of neurons, which acts through specific high-affinity (i.e., TrkA) and low-affinity (i.e., p75NTR) nerve growth factor receptors in the anterior segment of the eye to support corneal innervation and integrity. Efficacy and safety of Oxervate (cenegermin 20 mcg/mL) for treatment of patients with NK (N=151) was evaluated in two Phase 2, 8-week, randomized, multi-center, double-masked, vehicle-controlled studies (Study NGF0212 and Study NGF0214). In both studies, cenegermin was dosed 6 times daily in the affected eye(s) for 8 weeks. Results for the primary endpoint, “complete corneal healing” (i.e., absence of corneal lesion staining and no persistent staining in the rest of the cornea after 8 weeks of treatment) were as follows:(1)
In patients healed after 8 weeks of Oxervate (cenegermin 20 mcg/mL) therapy, recurrences occurred in about 20% of patients in Study NGF0212 and 14% of patients in Study NGF0214. Least square mean changes (improvement) from baseline in corneal sensitivity inside the lesion after 8 weeks of treatment were not clinically significant in either study:(1)
Inclusion criteria required patients to be 18 years of age with Stage 2 (persistent epithelial defect [PED]) or Stage 3 (corneal ulcer) NK (involving one eye for NGF0212 and involving both eyes for NGF0214); PED or corneal ulceration of greater than 2 weeks duration refractory to greater than 1 conventional non-surgical treatments for NK (e.g., preservative-free artificial tears, gels or ointments; discontinuation of preserved topical drops and medications that can decrease corneal sensitivity; therapeutic contact lenses); evidence of decreased corneal sensitivity (less than or equal to 4 cm on Cochet-Bonnet aesthesiometer) within area of the PED or corneal ulcer and outside of the area of the defect in greater than 1 corneal quadrant; best corrected distance visual acuity (BCDVA) score less than or equal to 75 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, (greater than or equal to +0.2 log MAR, less than or equal to 20/32 Snellen or less than or equal to 0.625 decimal fraction) in the affected eye; and no objective clinical evidence of improvement in PED or corneal ulceration within the 2 weeks prior to study enrollment.(4) |
Safety |
Oxervate has no FDA labeled contraindications for use.(1) |
REFERENCES
Number |
Reference |
1 |
Oxervate prescribing information. Dompé farmaceutici S.p.A. October 2023. |
2 |
Neurotrophic keratitis - EyeWiki. Published December 29, 2023. http://eyewiki.aao.org/Neurotrophic_Keratitis |
3 |
Sacchetti M, Lambìase A. Diagnosis and management of neurotrophic keratitis. Clinical Ophthalmology. Published online March 1, 2014:571. doi:10.2147/opth.s45921 |
4 |
Bonini S, Lambìase A, Rama P, et al. Phase II randomized, Double-Masked, Vehicle-Controlled trial of recombinant human nerve growth factor for neurotrophic keratitis. Ophthalmology. 2018;125(9):1332-1343. doi:10.1016/j.ophtha.2018.02.022 |
POLICY AGENT SUMMARY PRIOR AUTHORIZATION
Target Brand Agent(s) |
Target Generic Agent(s) |
Strength |
Targeted MSC |
Available MSC |
Final Age Limit |
Preferred Status |
|
||||||
Oxervate |
cenegermin-bkbj ophth soln |
0.002 % |
M ; N ; O ; Y |
N |
|
|
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|
|||||||||
Oxervate |
Cenegermin-bkbj Ophth Soln 0.002% (20 MCG/ML) |
0.002 % |
56 |
Vials |
56 |
DAYS |
|
|
|
CLIENT SUMMARY – PRIOR AUTHORIZATION
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
Oxervate |
cenegermin-bkbj ophth soln |
0.002 % |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
CLIENT SUMMARY – QUANTITY LIMITS
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
Oxervate |
Cenegermin-bkbj Ophth Soln 0.002% (20 MCG/ML) |
0.002 % |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
PRIOR AUTHORIZATION CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
PA |
Target Agent(s) will be approved when ALL of the following are met:
Length of Approval: 8 weeks *Step therapy requirement may not apply if a prior health plan paid for the medication - documentation of a paid claim may be required. |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
QL |
Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:
Length of Approval: up to 8 weeks |
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
ALBP _ Commercial _ CSReg _ Neurotrophic_Keratitis_PAQL _ProgSum_ 10-01-2024 _
© Copyright Prime Therapeutics LLC. June 2024 All Rights Reserved