Pharmacy Prior Authorization Criteria

Verkazia (cyclosporine ophthalmic emulsion 0.1%) - PA, NF

Indications for Prior Authorization

Verkazia (cyclosporine ophthalmic emulsion 0.1%)

• For diagnosis of Vernal Keratoconjunctivitis
  Indicated for the treatment of vernal keratoconjunctivitis in children and adults.

Criteria

Verkazia

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

• Diagnosis of moderate to severe vernal keratoconjunctivitis confirmed by the presence of clinical signs and symptoms (e.g., itching, photophobia, giant papillae at the upper tarsal conjunctiva or at the limbus, thick mucus discharge, conjunctival hyperaemia) [A, 1, 2, 3]
AND
• Trial and failure, contraindication, or intolerance to ONE of the following:
• Topical ophthalmic “dual-acting” mast cell stabilizer and antihistamine (e.g., olopatadine, azelastine)
• Topical ophthalmic mast cell stabilizers (e.g., cromolyn)
AND
• Trial and failure, contraindication, or intolerance, for short term use (up to 2 to 3 weeks), of topical ophthalmic corticosteroids (e.g., dexamethasone, prednisolone, fluoromethalone)
AND
• Prescribed by or in consultation with ONE of the following: [B ,3]
• Ophthalmologist
• Optometrist

Verkazia

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy as evidenced by an improvement in clinical signs and symptoms (e.g., itching, photophobia, papillary hypertrophy, mucus discharge, conjunctival hyperaemia)

Verkazia

Non Formulary

Length of Approval: 6 Month(s)

• Diagnosis of moderate to severe vernal keratoconjunctivitis confirmed by the presence of clinical signs and symptoms (e.g., itching, photophobia, giant papillae at the upper tarsal conjunctiva or at the limbus, thick mucus discharge, conjunctival hyperaemia) [A, 1, 2, 3]
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming trial and failure, contraindication, or intolerance to ONE of the following:
• Topical ophthalmic “dual-acting” mast cell stabilizer and antihistamine (e.g., olopatadine, azelastine)
• Topical ophthalmic mast cell stabilizers (e.g., cromolyn)
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming trial and failure, contraindication, or intolerance, for short term use (up to 2 to 3 weeks), of topical ophthalmic corticosteroids (e.g., dexamethasone, prednisolone, fluoromethalone)
AND
• Prescribed by or in consultation with ONE of the following: [B ,3]
• Ophthalmologist
• Optometrist

P & T Revisions

2024-04-04, 2023-10-04, 2023-04-21, 2022-08-16, 2022-05-20

References

1. Verkazia prescribing information. Santen, Inc. Emeryville, CA. June 2021.
2. Kumar, S. Vernal keratoconjunctivitis: a major review. Available at https://onlinelibrary.wiley.com/doi/10.1111/j.1755-3768.2008.01347.x. Accessed April 5, 2022.
3. UpToDate. Vernal keratoconjunctivitis. Available at https://www.uptodate.com/contents/vernal-keratoconjunctivitis?search=VERNAL%20KERATOCONJUNCTIVITIS&source=search_result&selectedTitle=1~12&usage_type=default&display_rank=1#H18. Accessed April 5, 2022.

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End Notes

1. No precise diagnostic criteria have been established for this disease. Diagnosis is based on typical clinical signs and symptoms; thus, many mild or atypical cases may escape diagnosis. The lack of standardized diagnostic criteria and lack of common language among physicians regarding the severity of VKC renders this disease more difficult to diagnose and treat. [2]
2. A short-term, high-dose pulse regimen of topical corticosteroids is often necessary in patients with VKC who fail to respond to two to three weeks of a dual-acting antihistamine/mast cell stabilizer, particularly those with significant seasonal exacerbations. Close follow-up with an ophthalmologist is required due to vision-threatening side effects of topical corticosteroids, such as glaucoma, cataracts, and secondary infections. Patients should know that blindness is a risk of unsupervised topical corticosteroid therapy. [3]

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Revision History

• 2024-04-04: 2024 Annual Review
• 2023-10-04: Program update to standard reauthorization language. No changes to clinical intent
• 2023-04-21: 2023 Annual Review.
• 2022-08-16: Update UM PA Criteria
• 2022-05-20: New PA Criteria

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