Verkazia — Blue Cross Blue Shield of Alabama
Other indication supported in compendia for the requested agent and route of administration
Preferred products
- Cequa
- Restasis
- Vevye
- Xiidra
Initial criteria
- Diagnosis of vernal keratoconjunctivitis (VKC)
- AND ONE of the following: • Tried and had an inadequate response to combination of a topical ophthalmic mast cell stabilizer AND an antihistamine used in the treatment of VKC OR • An intolerance or hypersensitivity to combination of a topical ophthalmic mast cell stabilizer AND an antihistamine OR • An FDA labeled contraindication to ALL topical ophthalmic mast cell stabilizers AND antihistamines
- AND ONE of the following: • Tried and had an inadequate response to ONE topical ophthalmic corticosteroid used in VKC OR • An intolerance or hypersensitivity to ONE topical ophthalmic corticosteroid OR • An FDA labeled contraindication to ALL topical ophthalmic corticosteroids
- OR The patient has another FDA labeled indication for the requested agent and route of administration
- OR The patient has another indication supported in compendia (AHFS or DrugDex 1 or 2a level of evidence) for the requested agent and route of administration
- AND The patient will NOT use the requested agent in combination with Cequa, Restasis, Vevye, or Xiidra
- AND The patient does NOT have any FDA labeled contraindications to the requested agent
Reauthorization criteria
- The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
- AND The patient has had clinical benefit with the requested agent
- AND The patient will NOT be using the requested agent in combination with Cequa, Restasis, Vevye, or Xiidra
- AND The patient does NOT have any FDA labeled contraindications to the requested agent
Approval duration
4 months initial, 12 months renewal