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Verkazia — Blue Cross Blue Shield of Texas

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) ONE of the following: (A) 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 (B) 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 (C) 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
  • The patient will NOT be using the requested agent in combination with Cequa, Restasis, Vevye, or Xiidra
  • The patient does NOT have any FDA labeled contraindications to the requested agent
  • Compendia Allowed: AHFS or DrugDex level 1, 2a, or 2b level of evidence
  • For Ohio residents in Fully Insured or HIM Shop (SG) plans: 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 journals supporting safety and effectiveness (excluding case studies)

Reauthorization criteria

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

Approval duration

initial 4 or 12 months; renewal 12 months