Vfend (voriconazole) — Blue Cross Blue Shield of New Mexico

Preferred products

• fluconazole

Initial criteria

• The patient has diagnosis of invasive aspergillosis OR
• For prophylaxis of invasive aspergillosis or Candida: requested agent used for prophylaxis AND patient is severely immunocompromised (e.g., HSCT recipient, hematologic malignancy with prolonged neutropenia, or high-risk solid organ transplant recipient) OR
• The patient has diagnosis of esophageal candidiasis, candidemia, or other deep tissue Candida infection AND ONE of the following:
• – Patient has stage 4 advanced metastatic cancer and requested agent used to treat cancer or associated condition AND use consistent with best practices, FDA approved, and supported by peer-reviewed literature OR
• – The patient has tried and had inadequate response to fluconazole OR
• – The patient has intolerance or hypersensitivity to fluconazole OR
• – The patient has FDA labeled contraindication to fluconazole OR
• The patient has a serious infection caused by Scedosporium or Fusarium species OR
• The patient has another FDA labeled indication OR an indication supported in compendia (AHFS, DrugDex 1, 2a, 2b) AND age is within FDA labeling or supported for age AND patient does NOT have FDA labeled contraindication
• Alternate Ohio approval: member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND patient has no labeled contraindication AND ONE of: another FDA labeled indication, compendia-supported indication, or submission of two peer-reviewed journal articles supporting safe and effective use (randomized, double blind, placebo controlled). Non-oncology compendia: DrugDex 1, 2A, or 2B, AHFS-DI; Oncology compendia: NCCN 1 or 2A, AHFS-DI, DrugDex 1–2B, Clinical Pharmacology, or LexiDrugs A.

Reauthorization criteria

• The patient has been previously approved for Vfend through prior authorization review AND
• ONE of the following:
• – The patient has diagnosis of invasive aspergillosis, serious infection caused by Scedosporium or Fusarium, esophageal candidiasis, candidemia, or other deep tissue Candida infection AND continued indicators of active disease OR
• – The patient has another diagnosis and there is support for continued use for that indication

Approval duration

BCBSIL/MT: 6 months; BCBSNM: esophageal candidiasis 3 months, others 6 months; other plans: esophageal candidiasis 1 month, others 6 months; Ohio route: 12 months