Pharmacy Prior Authorization Criteria

Ophthalmic Antihistamines

Indications for Prior Authorization

LASTACAFT (alcaftadine)

• For diagnosis of Allergic Conjunctivitis
  Indicated for the prevention of itching associated with allergic conjunctivitis.

ZERVIATE (cetirizine)

• For diagnosis of Allergic Conjunctivitis
  Indicated for the treatment of ocular itching associated with allergic conjunctivitis.

Criteria

Lastacaft, Zerviate

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (of a minimum 30-day supply), contraindication, or intolerance to both of the following generics or preferred brands:
• azelastine
• olopatadine

P & T Revisions

2024-09-02, 2023-11-01, 2022-11-02, 2021-11-30, 2021-09-22, 2021-05-20, 2020-12-29, 2020-09-09, 2019-10-02

References

1. Lastacaft Prescribing Information. Allergan, Inc, Irvine, CA. June 2020.
2. Zerviate Prescribing Information. Eyevance Pharmaceuticals, Lakewood, NJ. October 2023.

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Revision History

• 2024-09-02: 2024 Annual Review. Added in minimum trial duration.
• 2023-11-01: Annual Review, no changes.
• 2022-11-02: 2022 Annual Review
• 2021-11-30: update ST to remove Bepreve as a target drug.
• 2021-09-22: 2021 UM annual review.
• 2021-05-20: EHB specific guideline, added to EHB formulary, removed from ORx standard formulary. no changes to criteria
• 2020-12-29: Update ST to add Zerviate as target drug and remove Pataday as a trial and failure option.
• 2020-09-09: 2020 UM Annual Review.
• 2019-10-02: 2019 Annual Review. SL 10.02.2019

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