CurrentColorado Rocky Mountain Health PlansPolicy 2025 P 2274-4

Verkazia (cyclosporine 0.1%) prior authorization — vernal keratoconjunctivitis

Defines prior authorization and medical necessity criteria for coverage of Verkazia for treatment of vernal keratoconjunctivitis; applies to providers submitting requests under the payer's pharmacy/medical prior authorization program.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyVerkazia (cyclosporine 0.1%) prior authorization — vernal keratoconjunctivitis

Policy CodePolicy 2025 P 2274-4

Change TypeAnnual review (no material changes)

Effective DateAug 1, 2025

Next Review Date

Key ActionObtain prior authorization and document diagnosis of moderate to severe vernal keratoconjunctivitis plus trial/failure or contraindication/intolerance to two required medication categories.

SourceLink

POLICY UPDATE CHANGES

New prior authorization program for Verkazia was created.

Annual reviews were conducted in 2023, 2024, and 2025 with updated or no changes to criteria/references.

12 monthsauthorization duration

2required medication categories

moderate–severerequired disease severity

8/1/2025effective date

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Coverage and Medical Necessity Criteria

inv-01: Initial Authorization

Covered when ALL of the following are met

Initial authorization: Member has a diagnosis of moderate to severe vernal keratoconjunctivitis

Prior therapy requirement: History of failure, contraindication, or intolerance to two of the following medication categories: 1) ophthalmic antihistamines (e.g., azelastine, olopatadine), 2) ophthalmic mast cell stabilizers (e.g., cromolyn sodium), 3) ophthalmic corticosteroids (e.g., dexamethasone, prednisolone, fluorometholone)>=2 categories

Authorization issued for 12 months

inv-02: Reauthorization

Covered when ALL of the following are met

Reauthorization: Documentation of positive clinical response

Authorization issued for 12 months

Supply limits may apply to Verkazia (cyclosporine 0.1%) dispenses; providers should anticipate quantity or day-supply restrictions when submitting requests. The payer may use automated approval or reauthorization based on prior claim or medication history, diagnosis codes (ICD-10), and/or claim logic — approvals through these processes vary by program or therapeutic class and do not replace submission of supporting clinical documentation when requested.

Requests for Verkazia will be considered not medically necessary if there is no documented history of trial with and failure, contraindication, or intolerance to two of the required medication categories: ophthalmic antihistamines, ophthalmic mast cell stabilizers, and ophthalmic corticosteroids. Absence of documentation meeting this step-therapy requirement is a basis for denial.

Coding, References, and Related Data

References / package insertmixed

No codes listed

inv-06: Required prior therapy count

Required prior therapy count>= 2 medication categories: ophthalmic antihistamines, ophthalmic mast cell stabilizers, or ophthalmic corticosteroids

Examples of ophthalmic antihistaminesazelastine, olopatadine

Examples of ophthalmic mast cell stabilizerscromolyn sodium

Examples of ophthalmic corticosteroidsdexamethasone, prednisolone, fluorometholone

Authorization duration when criteria met12 months

Provider Requirements and Administrative Actions

Prior Authorization

Prior Authorization Required for Initial Therapy

Prior authorization is required for initial therapy with Verkazia (cyclosporine 0.1% ophthalmic emulsion). Approval requires a diagnosis of moderate to severe vernal keratoconjunctivitis and documentation of prior treatment history as specified.

Diagnosis: moderate to severe vernal keratoconjunctivitis
Required prior therapy: documented failure, contraindication, or intolerance to two of the following categories: (1) ophthalmic antihistamines (e.g., azelastine, olopatadine); (2) ophthalmic mast cell stabilizers (e.g., cromolyn sodium); (3) ophthalmic corticosteroids (e.g., dexamethasone, prednisolone, fluorometholone)
Authorization duration: 12 months

Step Therapy

Step Therapy Requirement

Step therapy is required: members must have a documented trial and failure, contraindication, or intolerance to two of the specified medication classes before Verkazia is approved.

Required trials: two of the following classes — ophthalmic antihistamines; ophthalmic mast cell stabilizers; ophthalmic corticosteroids

Background and Indication

Verkazia (cyclosporine 0.1%) ophthalmic emulsion is indicated for vernal keratoconjunctivitis and is covered under prior authorization when the member has a diagnosis of moderate to severe vernal keratoconjunctivitis and has a documented history of failure, contraindication, or intolerance to two medication categories among ophthalmic antihistamines (e.g., azelastine, olopatadine), ophthalmic mast cell stabilizers (e.g., cromolyn sodium), and ophthalmic corticosteroids (e.g., dexamethasone, prednisolone, fluorometholone). Authorization, when approved, is issued for 12 months. Supply limits may be in place and automated approvals based on prior claims, medication history, or diagnosis coding may be used per program rules.

Definitions

inv-12: Vernal keratoconjunctivitis

DefinitionAn allergic inflammatory condition of the conjunctiva and cornea; affects children and adults

Typical first-line topical treatmentsOphthalmic antihistamines and mast cell stabilizers

Adjunct/short-term therapyOphthalmic corticosteroids for inflammatory control

Indication relevant to policyVerkazia (cyclosporine 0.1%) is indicated for vernal keratoconjunctivitis