Pharmacy Prior Authorization Criteria

Ophthalmic Anti-Allergic Agents

Indications for Prior Authorization

Bepreve (bepotastine)

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

Zerviate (cetirizine)

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

Criteria

Brand Bepreve, generic bepotastine, 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:
• azelastine
• olopatadine

P & T Revisions

2025-01-30, 2024-09-02, 2023-11-01, 2023-01-03, 2022-11-02, 2021-09-22, 2021-06-30, 2021-06-04, 2020-09-09, 2020-03-24, 2019-10-07

References

1. Bepreve Prescribing Information. Bausch + Lomb, a division of Valeant Pharmaceuticals North America LLC. Bridgewater, NJ. August 2023.
2. Zerviate Prescribing Information. Eyevance Pharmaceuticals, LLC. Fort Worth, TX. October 2023.

---

Revision History

• 2025-01-30: removal of Lastacaft product from guideline
• 2024-09-02: 2024 Annual Review. No criteria changes.
• 2023-11-01: Annual Review, no changes.
• 2023-01-03: Pazeo criteria and associated information was removed from guideline as product is obsolete and has little to no utilization.
• 2022-11-02: 2022 Annual Review
• 2021-09-22: 2021 UM annual review.
• 2021-06-30: Program update to add generic bepotastine as a target drug to mirror its brand.
• 2021-06-04: Program update to add Pazeo as a target drug.
• 2020-09-09: 2020 UM Annual Review.
• 2020-03-24: Update to add Zerviate
• 2019-10-07: Updated ST criteria.

---