Tolsura (itraconazole) — Blue Cross Blue Shield of Montana

other FDA labeled indication

Preferred products

Patient is currently being treated with the requested agent and stable on therapy 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 or cause significant barrier to adherence, worsen comorbid condition, decrease functional ability, cause adverse reaction or harm OR
Vfend or Noxafil not in best interest of patient based on medical necessity OR
Patient has tried another agent in same class or with same mechanism as Vfend or Noxafil which was discontinued due to lack of efficacy, diminished effect, or adverse event OR
For diagnosis of blastomycosis or histoplasmosis, patient meets any of the following: is currently stable on requested agent; tried and failed generic itraconazole; intolerance, hypersensitivity, or contraindication to itraconazole; generic itraconazole expected to be ineffective or not in best interest; tried another drug in same class with failure
If patient has another FDA labeled indication or compendia-supported indication for requested agent and route, patient’s age is within FDA labeling or there is supporting evidence for use at that age, and patient has no FDA labeled contraindication
Compendia Allowed: AHFS or DrugDex 1, 2a, or 2b level of evidence

Patient previously approved for requested agent through prior authorization process AND
Patient does not have any FDA labeled contraindications AND
One of the following: (A) diagnosis of aspergillosis, blastomycosis, or histoplasmosis with continued indicators of active disease (biomarkers, biopsy, culture, radiographic evidence) OR (B) diagnosis other than those listed with support for continued use for requested indication

6 months