VERKAZIA (cyclosporine ophthalmic emulsion)

VERKAZIA (cyclosporine ophthalmic emulsion)

Self-Administration – ophthalmic

Diagnosis considered for coverage:

Indicated for the treatment of vernal keratoconjunctivitis (VKC) in children and adults

Coverage Criteria:

For diagnosis of VKC:

• Dose does not exceed one drop into each affected eye 4 times daily (120 single-dose vials per 30-day supply or 360 single-dose vials per 90-day supply); AND
• Patient is 4 years of age or older; AND
• Diagnosis of moderate to severe vernal keratoconjunctivitis confirmed by the presence of clinical signs and symptoms (e.g., itching, photophobia, giant papillae at the upper tarsal conjunctiva or at the limbus, thick mucus discharge, conjunctival hyperaemia); AND
• Prescribed by or in consultation with ophthalmologist or optometrist; AND
• Trial and failure, contraindication, or intolerance to one of the following:
  • Topical ophthalmic “dual-acting” mast cell stabilizer and antihistamine (e.g., olopatadine, azelastine) 
  • Topical ophthalmic mast cell stabilizers (e.g., cromolyn); AND
• Trial and failure, contraindication, or intolerance, for short term use (up to 2 to 3 weeks), of topical ophthalmic corticosteroids (e.g., dexamethasone, prednisolone, fluorometholone)

Reauthorization Criteria:

For diagnosis of VKC:

• Dose does not exceed one drop into each affected eye 4 times daily (120 single-dose vials per 30-day supply or 360 single-dose vials per 90-day supply); AND
• Prescribed by or in consultation with ophthalmologist or optometrist; AND
• Documentation of positive clinical response to therapy as evidenced by an improvement in clinical signs and symptoms (e.g., itching, photophobia, papillary hypertrophy, mucus discharge, conjunctival hyperaemia)

Coverage Duration: 

• Initial: 6 months
• 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 (P&T) Committee.

Additional Information: 

• Recommended Dose: one drop into each affected eye 4 times daily
• There is enough medicine in one single-dose vial to use in both eyes

Policy Updates:

• 8/16/2022 – New policy approved by P&T

References:

• Verkazia prescribing information. Santen, Inc. Emeryville, CA. June 2021. 
• Kumar, S. Vernal keratoconjunctivitis: a major review. Available at https://onlinelibrary.wiley.com/doi/10.1111/j.1755-3768.2008.01347.x. Accessed April 5, 2022.