Vivjoa (oteseconazole) — Blue Cross Blue Shield of Illinois

Initial criteria

• ALL of the following: the patient has a diagnosis of recurrent vulvovaginal candidiasis (RVVC) AND the patient has experienced ≥ 2 episodes of vulvovaginal candidiasis within a 12 month period AND ONE of the following:
• A. BOTH of the following: ONE of the following: the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to the cancer [chart notes required] AND the use of the requested agent is consistent with best practices, supported by peer-reviewed, evidence-based literature, and FDA approved OR
• B. The patient will be using fluconazole in combination with the requested agent OR
• C. The patient has tried and had an inadequate response to fluconazole OR
• D. The patient has an intolerance or hypersensitivity to fluconazole OR
• E. The patient has an FDA labeled contraindication to fluconazole OR
• B. The patient has another FDA labeled indication for the requested agent and route of administration OR
• C. The patient has another indication that is supported in compendia for the requested agent and route of administration AND the patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

BCBSIL and BCBSMT: 6 months; all other plans: RVVC - 4 months, other indications - 6 months