Verkazia Cyclosporine Vernal Keratoconjunctivitis User Guide

STANDARD COMMERCIAL DRUG FORMULARY
PRIOR AUTHORIZATION GUIDELINES
CYCLOSPORINE
User Guide

CYCLOSPORINE Vernal Keratoconjunctivitis

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.

Part D Effective: N/A
Commercial Effective: 10/01/22
Created: 08/22
Client Approval: 09/22
P&T Approval: 07/22
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