Verkazia — Blue Cross Blue Shield of Montana

Initial criteria

• Diagnosis of vernal keratoconjunctivitis (VKC) AND ONE of the following: (1) Tried and had inadequate response to combination of a topical ophthalmic mast cell stabilizer AND an antihistamine used in the treatment of VKC OR (2) Has intolerance or hypersensitivity to combination of a topical ophthalmic mast cell stabilizer AND an antihistamine used in the treatment of VKC OR (3) Has an FDA labeled contraindication to ALL topical ophthalmic mast cell stabilizers AND antihistamines OR
• Patient has another FDA labeled indication for the requested agent OR
• Patient has another indication that is supported in compendia for the requested agent and route of administration
• Patient will NOT be using the requested agent in combination with Cequa, Restasis, Vevye, or Xiidra
• Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• Patient has had clinical benefit with the requested agent
• Patient will NOT be using the requested agent in combination with Cequa, Restasis, Vevye, or Xiidra
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months (BCBSIL); 4 months (all other plans)