VERKAZIA CYCLOSPORINE Vernal Keratoconjunctivitis User Guide
- June 3, 2024
- VERKAZIA
Table of Contents
STANDARD COMMERCIAL DRUG FORMULARY
PRIOR AUTHORIZATION GUIDELINES
CYCLOSPORINE
User Guide
CYCLOSPORINE Vernal Keratoconjunctivitis
| Generic | Brand | HICL | GCN | Medi-Span | Exception/Other |
|---|---|---|---|---|---|
| CYCLOSPORINE | VERNAZZA | 46848 | GPI-14 (86720020001630) |
GUIDELINES FOR USE
1. Does the patient have a diagnosis of vernal keratoconjunctivitis AND
meet the following criterion?
• The patient had a trial of or contraindication to TWO ophthalmic dual-
acting mast cell stabilizers/antihistamines (e.g., ketotifen) or mast cell
stabilizers (e.g., cromolyn)
If yes, approve for 12 months by GPID or GPI-14 with a quantity limit of #4
vials per day.
If no, do not approve.
DENIAL TEXT: *Some terms are already pre-defined in parenthesis. Please
use these definitions if the particular text you need to use does not already
have a definition(s) in it.
Our guideline named CYCLOSPORINE (Verkazia) requires the following rule(s) to
be met for approval:
A. You have vernal keratoconjunctivitis (allergic eye disease)
B. You had a trial of or contraindication (harmful for) to TWO ophthalmic
dual-acting mast cell stabilizers/antihistamines (such as ketotifen) or mast
cell stabilizers (such as cromolyn)
Your doctor told us [INSERT PT SPECIFIC INFO PROVIDED]. We do not have
information showing you [INSERT UNMET CRITERIA]. This is why your request is
denied. Please work with your doctor to use a different medication or get us
more information if it will allow us to approve this request.
RATIONALE
For further information, please refer to the Prescribing Information and/or
Drug Monograph for Verkazia.
REFERENCES
• Vernazza [Prescribing Information]. Emeryville, CA: Santen Inc.; June 2022.
| Library | Commercial | NSA |
|---|---|---|
| Yes | Yes | No |
Part D Effective: N/A
Commercial Effective: 10/01/22
Created: 08/22
Client Approval: 09/22
P&T Approval: 07/22
Copyright © 2022 MedImpact Healthcare Systems, Inc. All rights reserved. This
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MedImpact maintains the sole and exclusive ownership, right, title, and
interest in and to this document.
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