Arikayce — Blue Cross Blue Shield of Kansas

Initial criteria

• Patient has Mycobacterium avium complex (MAC) lung disease
• Patient is receiving guideline-based combination antibiotic therapy for MAC lung disease that includes a macrolide (clarithromycin or azithromycin), a rifamycin (rifampin or rifabutin), and ethambutol
• Prescriber is a specialist in the area of the patient’s diagnosis (infectious disease, immunologist, pulmonologist, or thoracic specialist) or has consulted with a specialist in the area of the patient’s diagnosis
• ONE of the following: A. Patient is NOT currently being treated with another inhaled antibiotic (e.g., aztreonam for inhalation, tobramycin for inhalation) OR B. Patient is currently being treated with another inhaled antibiotic AND ONE of the following: 1. Patient will discontinue the other inhaled antibiotic prior to starting the requested agent OR 2. There is support for the use of another inhaled antibiotic concurrently with the requested agent
• Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• Patient has had clinical benefit with the requested agent
• Patient will continue treatment with guideline-based combination antibiotic therapy for MAC lung disease with the requested agent (e.g., combination may include a macrolide [clarithromycin, azithromycin], a rifamycin [rifampin, rifabutin], and ethambutol)
• Prescriber is a specialist in the area of the patient’s diagnosis (infectious disease, immunologist, pulmonologist, or thoracic specialist) or has consulted with a specialist in the area of the patient’s diagnosis
• ONE of the following: A. Patient is NOT currently being treated with another inhaled antibiotic (e.g., aztreonam for inhalation, tobramycin for inhalation) OR B. Patient is currently being treated with another inhaled antibiotic AND ONE of the following: 1. Patient will discontinue the other inhaled antibiotic prior to starting the requested agent OR 2. There is support for the use of another inhaled antibiotic concurrently with the requested agent
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months