Vfend (voriconazole) — Blue Cross Blue Shield of Montana

other deep tissue Candida infection

Preferred products

Patient has diagnosis of invasive aspergillosis OR
Patient receiving prophylaxis of invasive aspergillosis or Candida and is severely immunocompromised (hematopoietic stem cell transplant recipient, hematologic malignancy with prolonged neutropenia, or high-risk solid organ transplant recipient) OR
Patient has diagnosis of esophageal candidiasis, candidemia, or other deep tissue Candida infection AND one of the following: (A) meets stage four advanced metastatic cancer criteria with use consistent with best practices; (B) tried and inadequately responded to fluconazole; (C) intolerance or hypersensitivity to fluconazole; (D) FDA labeled contraindication to fluconazole OR
Patient has serious infection caused by Scedosporium or Fusarium species OR
Patient has another FDA labeled indication or compendia-supported indication for requested agent and route AND patient’s age is appropriate or supported for use 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 has one of the following: (A) diagnosis of invasive aspergillosis, serious infection caused by Scedosporium or Fusarium species, esophageal candidiasis, candidemia, or deep tissue Candida infection AND continued clinical need documented

6 months