Vfend (voriconazole) — Blue Cross Blue Shield of Illinois

other FDA labeled indication

Preferred products

Diagnosis of invasive aspergillosis OR
Prophylaxis of invasive aspergillosis or Candida AND patient is severely immunocompromised (e.g., HSCT, hematologic malignancy with prolonged neutropenia, high-risk solid organ transplant) OR
Diagnosis of esophageal candidiasis, candidemia, or other deep tissue Candida infection AND ONE of the following: (stage 4 advanced metastatic cancer with treatment consistent with best practices) OR inadequate response to fluconazole OR intolerance or hypersensitivity to fluconazole OR FDA labeled contraindication to fluconazole OR
Diagnosis of serious infection caused by Scedosporium or Fusarium species OR
Other FDA labeled indication or compendia supported indication AND
If patient has an 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 plan prior authorization review AND
EITHER: (diagnosis of invasive aspergillosis; serious infection caused by Scedosporium or Fusarium species; esophageal candidiasis; candidemia; or deep tissue Candida infection) OR (other diagnosis supported for continued use)

6 months (BCBSIL/BCBSMT); 3 months (BCBSNM esophageal candidiasis)/6 months others; 1 month (other plans esophageal candidiasis)/6 months others