Medicare AdvantagePrior AuthMedium impact
Verkazia® (cyclosporine) (Revised)
Humana·Ophthalmology, Optometry·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its prior authorization policy for Verkazia (cyclosporine) eye drops effective January 1, 2026 (revised April 22, 2026). Coverage now requires documented diagnosis of vernal keratoconjunctivitis (VKC) AND prior treatment failure/contraindication/intolerance to at least TWO specific topical agents (cromolyn, dexamethasone, prednisolone acetate, or fluorometholone) before approval. This is a Prior Authorization requirement that billing teams must enforce for all Verkazia claims.
Action Required
By December 31, 2025: Billing team and clinical staff must implement prior authorization process for all Verkazia (cyclosporine) ophthalmic emulsion claims. (1) Update billing system to flag Verkazia prescriptions for mandatory prior authorization review. (2) Create/update prior auth submission checklist requiring: confirmed VKC diagnosis AND documentation of failed/contraindicated/intolerant treatment with minimum TWO of the following agents—cromolyn eye drops, dexamethasone sodium phosphate eye drops, prednisolone acetate eye drops/suspension, or fluorometholone eye drops/suspension. (3) Inform providers and clinical staff of revised criteria and documentation requirements. (4) Review existing Verkazia claims since revision date (April 22, 2026) for compliance; resubmit any missing documentation. Failure to obtain prior authorization before dispensing Verkazia will result in claim denials for Medicare Advantage members.