ZERVIATE (cetirizine)

ZERVIATE (cetirizine)

SELF ADMINISTRATION- OPHTHALMIC SOLUTION

Indication for Prior Authorization:

Treatment of ocular itching associated with allergic conjunctivitis

Coverage Criteria:

• Patient is 2 years of age or older, AND 
• Diagnosis of ocular itching associated with allergic conjunctivitis, AND
• Patient has tried and failed Azelastine, Olopatadine, and Ketotifen as confirmed by chart note documentation 

Dosing:

• One drop in each affected eye twice daily

Coverage Duration:

• Initial: 1 year
• Reauthorization: 1 year

Authorization is Not Covered for the Following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics Committee.

Additional Information:

• Contamination of Tip and Solution: care should be taken not to touch the eyelids or surrounding areas with the dropper tip of the bottle or tip of the single- use container in order to avoid injury to the eye and to prevent contaminating the tip and solution. Keep the multi-dose bottle closed when not in use. Discard the single-use container after using in each eye
• Contact Lens Wear: Patients should be advised not to wear a contact lens if their eye is red. Zerviate™ should not be instilled while wearing contact lenses. Lenses may be reinserted 10 minutes following administration of Zerviate™

Review History:

10/20/20- Original review

References:

• Bepreve Prescribing Information. Bausch + Lomb, a division of Valeant Pharmaceuticals North America LLC. Bridgewater, NJ. September 2019. 
• Lastacaft Prescribing Information. Allergan, Inc. Irvine, CA. September 2015. 
• Zerviate Prescribing Information. Eyevance Pharmaceuticals, LLC. Fort Worth, TX. February 2020.