Vivjoa (oteseconazole) — Blue Cross Blue Shield of New Mexico

Initial criteria

• ALL of the following: 1) The patient has a diagnosis of recurrent vulvovaginal candidiasis (RVVC); AND 2) The patient has experienced ≥ 2 episodes of vulvovaginal candidiasis within a 12 month period; AND 3) ONE of the following: A) BOTH of the following: i) ONE of the following: The patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR to treat an associated condition related to stage four advanced, metastatic cancer [chart notes required]; AND ii) The use of the requested agent is consistent with best practices for treatment of stage four advanced metastatic cancer or associated condition, supported by peer-reviewed evidence-based literature, and FDA approved; OR B) The patient will be using fluconazole in combination with the requested agent; OR C) The patient has tried and had an inadequate response to fluconazole; OR D) The patient has an intolerance or hypersensitivity to fluconazole; OR E) The patient has an FDA labeled contraindication to fluconazole
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

BCBSIL/BCBSMT 6 months; all other plans 4 months for RVVC, 6 months for other indications