Brexafemme (ibrexafungerp) — Blue Cross Blue Shield of Montana

recurrent vulvovaginal candidiasis (RVVC)

Initial criteria

Patient is an adult or post-menarchal pediatric patient
AND ONE of the following:
• Patient has a diagnosis of vulvovaginal candidiasis (VVC)
• BOTH of the following: (a) Patient is using the requested agent to reduce the incidence of recurrent vulvovaginal candidiasis (RVVC) AND (b) Patient has experienced ≥ 2 episodes of VVC within a 12-month period
AND ONE of the following:
• BOTH of the following: (a) Patient has been diagnosed with stage four advanced, metastatic cancer AND (b) the requested agent is used to treat the cancer or an associated condition, consistent with best practices, literature-supported, and FDA approved
• Patient has tried and had an inadequate response to fluconazole
• Patient has an intolerance or hypersensitivity to fluconazole
• Patient has an FDA labeled contraindication to fluconazole
• Patient has another FDA labeled indication for the requested agent and route of administration
• Patient has another indication supported in compendia for the requested agent and route of administration
Patient does NOT have any FDA labeled contraindications to the requested agent

6 months