Anti-Allergy Ophthalmic Agents (Zerviate and Alrex) — Coverage Criteria
Customize your policy alerts
Sign up for Blue Cross Blue Shield - Iowa Policy 05.04.05 alerts
Get alerted when Policy 05.04.05 changes without checking for updates manually.
Monitor payer policy activity
Defines medical necessity and coverage criteria for prescription anti-allergy ophthalmic agents Zerviate (cetirizine) and Alrex (loteprednol) for treatment of allergic conjunctivitis; affects providers prescribing these agents for Wellmark Blue Cross and Blue Shield members in Iowa.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy
Covered when ALL of the following are met
Approval will be for 12 months.
Continuation Therapy
Covered for continuation when ALL of the following are met
Approval will be for 12 months.
Zerviate and Alrex are considered not medically necessary for patients who do not meet the criteria set forth in this policy.
Prior authorization requires documentation of a failed trial, contraindication, or adverse reaction to the specified over‑the‑counter ophthalmic anti‑allergy agents (Pataday Once Daily Relief Extra Strength; Pataday Once Daily Relief; Pataday Twice Daily Relief; and ketotifen 0.025% solution) and to both listed generic ophthalmic antihistamine products (azelastine 0.05% solution and epinastine 0.05% solution) before Zerviate or Alrex will be considered medically necessary.
Provider Coding Guidance
Provider Actions and Requirements
Prior Authorization Required
Prior authorization is required. Requests must document that the patient has had an inadequate response, a contraindication, or an adverse reaction to ALL of the listed OTC ophthalmic anti‑allergy agents (Pataday Once Daily Relief Extra Strength; Pataday Once Daily Relief; Pataday Twice Daily Relief; ketotifen 0.025% solution) unless the member is already receiving a positive therapeutic outcome on the requested medication through health insurance (samples or manufacturer patient assistance programs do not satisfy this). Approval will be for 12 months.
- Applies to Zerviate® and Alrex®
Step Therapy Requirements
Step therapy requires documented inadequate response, contraindication, or adverse reaction to ALL specified OTC ophthalmic anti‑allergy agents listed above, and to BOTH specified generic ophthalmic antihistamine products (azelastine 0.05% solution and epinastine 0.05% solution), unless the member is currently receiving a positive therapeutic outcome on the requested medication through health insurance (samples or manufacturer patient assistance programs do not satisfy this).
- OTC agents: Pataday Once Daily Relief Extra Strength; Pataday Once Daily Relief; Pataday Twice Daily Relief; ketotifen 0.025% solution
- Generics required: azelastine 0.05% solution; epinastine 0.05% solution
Denial Risk for Not Meeting Criteria
Failure to provide documentation of trials, contraindications, or adverse reactions to the required OTC agents and both generics places the request at risk for denial as not medically necessary.
- Denial risk if lack of documented trial/failure/contraindication/adverse reaction to all listed OTC agents and both listed generics
Required Documentation
Documentation submitted for prior authorization must clearly show inadequate response, contraindication, or adverse reaction to each of the specified OTC agents and to both specified generics, or documentation that the member is currently receiving a positive therapeutic outcome on the requested medication through health insurance.
- Required documented agents: Pataday Once Daily Relief Extra Strength; Pataday Once Daily Relief; Pataday Twice Daily Relief; ketotifen 0.025% solution; azelastine 0.05% solution; epinastine 0.05% solution
- Samples or manufacturer patient assistance program obtainment do not meet documentation requirements
Background
Allergic conjunctivitis causes ocular itching and inflammation. Zerviate (cetirizine ophthalmic solution) is an H1‑receptor antagonist indicated for treatment of ocular itching associated with allergic conjunctivitis in patients aged 2 years and older. Alrex (loteprednol etabonate ophthalmic suspension) is a topical corticosteroid indicated for temporary relief of signs and symptoms of seasonal allergic conjunctivitis.
Definitions / Drug Indications
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.