Verkazia — Medical Mutual

Initial criteria

• Patient is age ≥ 4 years; AND
• According to the prescriber, the patient has moderate to severe vernal keratoconjunctivitis; AND
• Patient meets one of the following (i or ii):
• i. Patient has tried two single-action ophthalmic medications (ophthalmic mast-cell stabilizers or ophthalmic antihistamines) for the maintenance treatment of vernal keratoconjunctivitis; OR
• ii. Patient has tried one dual-action ophthalmic mast-cell stabilizer/antihistamine product for the maintenance treatment of vernal keratoconjunctivitis; AND
• Note: An exception to this requirement can be made if the patient has already tried at least one ophthalmic cyclosporine product (e.g., Cequa [cyclosporine 0.09% ophthalmic solution], cyclosporine 0.05% ophthalmic emulsion [Restasis, generic], Vevye [cyclosporine 0.1% ophthalmic solution]) other than the requested medication.
• The medication is prescribed by or in consultation with an optometrist or ophthalmologist.

Reauthorization criteria

• Response to therapy is required for continuation of therapy.

Approval duration

365 days