Product Details

Verkazia

Cyclosporine
0.1%
Topical Ophthalmic Emulsion
Single-Dose 0.3-mL LDPE Container (Unpreserved)

DIN/PIN/NPN

02484137

Manufacturer

Santen Incorporated

Formulary Listing Date

2021-03-03  

Unit Price

3.6667

Amount MOH Pays

3.6667

Coverage Status

Exceptional Access Program Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

S01XA18

Interchangeable Products

NO  

LU Clinical Criteria

NO  

EAP Criteria

Therapeutic Class Reimbursement Criteria
Ocular Treatments

Cyclosporine 0.1% eye drops

  • Brand(s): Verkazia
  • Dosage Form/Strength: 0.1% eye drops
  • Effective date: March 3, 2021

Initiation criteria:

For the treatment of severe vernal keratoconjunctivitis (VKC) in patients who meet ALL the following criteria: 

  1. Patient is between 4 and 18 years of age inclusive; AND

  2. Diagnosis of severe VKC as defined by one of the following evaluations of severity:
    •     Grade 3 (severe) or 4 (very severe) on the Bonini Scale;
    OR
    •     Grade 4 (marked) or 5 (severe) on the modified Oxford Scale;

    AND

  3. Documentation detailing the patient’s baseline severity of signs and symptoms of VKC is provided prior to treatment initiation with Verkazia; AND

  4. Patient is under the care of a physician with expertise in the diagnosis and management of VKC. 

Note: Patients previously treated with cyclosporine 0.1% but who discontinued treatment upon resolution of VKC signs and symptoms are eligible to reinitiate treatment if signs and symptoms of severe VKC recur and they meet the first and second initiation criteria.

Initial approval period: 6 months

Exclusion criteria:

Verkazia will not be funded in patients meeting ANY of the following criteria:

  • Patient is older than 18 years of age; 

  • Patient has asymptomatic, pre-symptomatic, or moderate VKC; 

  • Patients with active or suspected ocular or peri-ocular infection; 

  • Patients with ocular malignancies or premalignant conditions.

Discontinuation Criteria: 

Verkazia will not be funded upon meeting ONE or more of the following:

  • There is no demonstrated observable improvement in the patient’s VKC signs and symptoms after 4 months of Verkazia therapy (compared to baseline); OR 

  • The patient’s VKC signs and symptoms have been resolved.

Case-by-case consideration may be provided for patients who have responded to therapy but who continue to experience recurrent VKC symptoms

EAP Drug Request Form:

Standard Form for EAP Drug Requests

Product Monograph

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