Tolsura (itraconazole) — Blue Cross Blue Shield of Illinois

aspergillosis

Preferred products

Patient is currently being treated with the requested agent and is stable on the requested agent OR
Patient has tried and had an inadequate response to Vfend or Noxafil OR
Vfend or Noxafil discontinued due to lack of efficacy, diminished effect, or adverse event OR
Patient has intolerance or hypersensitivity to Vfend or Noxafil OR
Patient has an FDA labeled contraindication to Vfend AND Noxafil OR
Vfend or Noxafil expected to be ineffective based on clinical characteristics; OR cause adherence barrier; OR worsen comorbidity; OR decrease function; OR cause adverse reaction or harm OR
Vfend or Noxafil not in the best interest of the patient based on medical necessity OR
Patient tried another prescription drug in same pharmacologic class or with same mechanism as Vfend or Noxafil and discontinued due to lack of efficacy, diminished effect or adverse event OR
For blastomycosis or histoplasmosis: ONE of following applies: currently treated and stable, or inadequate response to generic itraconazole, or intolerance, contraindication, ineffectiveness, or not in best interest, or prior trial of similar class discontinued OR
Patient may have another FDA labeled or compendia supported indication AND
If patient has FDA labeled indication, age within labeling or supported for indication AND
Patient does not have any FDA labeled contraindications to requested agent

Patient has been previously approved for the requested agent through prior authorization review AND
Patient does not have any FDA labeled contraindications to requested agent AND
EITHER: (patient has diagnosis of aspergillosis, blastomycosis, or histoplasmosis AND continued indicators of active disease such as biomarkers, culture, or radiographic evidence) OR (patient has other diagnosis supported for continued use)

6 months