Cayston — Blue Cross Blue Shield of Alabama

Preferred products

• Generic tobramycin inhalation solution 300 mg/5 mL ampules (neb)

Initial criteria

• The patient has a diagnosis of cystic fibrosis with Pseudomonas aeruginosa respiratory infection AND
• ONE of the following:
• - The patient is NOT currently (within the past 60 days) being treated with another inhaled antibiotic (e.g., Arikayce, inhaled aztreonam, inhaled tobramycin) OR
• - The patient is currently (within the past 60 days) being treated with another inhaled antibiotic (e.g., Arikayce, inhaled aztreonam, inhaled tobramycin) AND ONE of the following:
• - The other inhaled antibiotic will be discontinued and that therapy will be continued only with the requested agent OR
• - There is support for using another inhaled antibiotic therapy concurrently with, or alternating with (i.e., continuous alternating therapy), the requested agent AND
• ONE of the following:
• - The requested agent is Bethkis, Cayston, Kitabis Pak, or TOBI OR
• - The requested agent is a preferred inhaled antibiotic agent OR
• - The patient has tried and had an inadequate response to a preferred inhaled antibiotic agent OR
• - The patient has an intolerance or hypersensitivity to a preferred inhaled antibiotic agent that is NOT expected to occur with the requested agent OR
• - The patient has an FDA labeled contraindication to ALL preferred inhaled antibiotic agents that is NOT expected to occur with the requested agent

Approval duration

12 months