Verkazia — Blue Cross Blue Shield of Oklahoma

Initial criteria

• ONE of the following:
• A. The patient has a diagnosis of vernal keratoconjunctivitis (VKC) AND ONE of the following:
• 1. The patient has 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
• 2. The patient has an intolerance or hypersensitivity to combination of a topical ophthalmic mast cell stabilizer AND an antihistamine used in the treatment of VKC OR
• 3. The patient has an FDA labeled contraindication to ALL topical ophthalmic mast cell stabilizers AND antihistamines OR
• B. The patient has another FDA labeled indication for the requested agent OR
• C. The patient has another indication that is supported in compendia for the requested agent and route of administration 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
• Compendia Allowed: AHFS or DrugDex 1, 2a, or 2b level of evidence
• For members residing in Ohio AND plan Fully Insured or HIM Shop (SG): BOTH of the following:
• A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
• B. ONE of the following:
• 1. The patient has another FDA labeled indication for the requested agent and route of administration OR
• 2. The patient has another indication that is supported in compendia for the requested agent and route of administration OR
• 3. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective

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

12 months (BCBSIL initial and renewal); 4 months (all other initial)