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Verkazia — Blue Cross Blue Shield of Oklahoma

vernal keratoconjunctivitis (VKC)

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)