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Noxafil (posaconazole) — Blue Cross Blue Shield of Illinois

invasive aspergillosis

Initial criteria

  • 1. ONE of the following:
  • A. The patient has a diagnosis of oropharyngeal candidiasis AND ONE of the following options regarding prior therapy, intolerance, contraindication, expectation of ineffectiveness, or medical necessity related to itraconazole and fluconazole; OR
  • B. BOTH of the following:
  • 1. Requested agent is prescribed for prophylaxis of invasive aspergillosis or Candida AND
  • 2. Patient is severely immunocompromised (e.g., HSCT recipient, hematologic malignancy with prolonged neutropenia) or is a high-risk solid organ transplant recipient OR
  • C. The patient has a diagnosis of invasive aspergillosis AND has had inadequate response, intolerance, contraindication, or other medically necessary reasons for not using voriconazole, amphotericin B, or isavuconazole OR
  • D. Patient has another FDA approved indication for requested agent and route of administration OR
  • E. Patient has another compendia-supported indication for requested agent and route of administration AND
  • 2. If the patient has an FDA labeled indication, then ONE of the following:
  • A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
  • B. Support exists for using the requested agent for the patient’s age for the requested indication AND
  • 3. The patient does NOT have any FDA labeled contraindications to the requested agent
  • Additional approval pathway:
  • Member resides in Ohio AND the plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
  • A. Patient has no FDA labeled contraindications AND
  • B. ONE of the following:
  • 1. Patient has another FDA labeled indication for the requested agent and route of administration OR
  • 2. Patient has another compendia-supported indication OR
  • 3. Prescriber submits two peer-reviewed journal articles supporting proposed use as safe and effective

Reauthorization criteria

  • 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization review process AND
  • 2. ONE of the following:
  • A. BOTH of the following:
  • 1. Requested agent is prescribed for prophylaxis of invasive Aspergillus or Candida AND
  • 2. Patient continues to be severely immunocompromised (e.g., HSCT recipient, hematologic malignancy with prolonged neutropenia) or is a high-risk solid organ transplant recipient OR
  • B. BOTH of the following:
  • 1. The patient has a diagnosis of invasive aspergillosis AND
  • 2. The patient has continued indicators of active disease (e.g., biomarkers, biopsy, microbiologic cultures, radiographic evidence) OR
  • C. BOTH of the following:
  • 1. The patient has a diagnosis other than invasive aspergillosis or prophylaxis of invasive Aspergillus or Candida AND
  • 2. There is support for continued use of the requested agent for the requested indication AND
  • 3. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

6 months