Vfend (voriconazole) — Blue Cross Blue Shield of Oklahoma

Preferred products

• fluconazole

Initial criteria

• 1. ONE of the following:
• • The patient has diagnosis of invasive aspergillosis OR
• • The requested agent is for prophylaxis of invasive aspergillosis or Candida AND patient is severely immunocompromised (e.g., HSCT recipient, hematologic malignancy with prolonged neutropenia from chemotherapy) 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:
• - Patient meets metastatic cancer criteria (stage four advanced/metastatic cancer and use consistent with best practices and FDA labeling) OR
• - The patient has tried and had inadequate response to fluconazole OR
• - The patient has intolerance or hypersensitivity to fluconazole OR
• - The patient has an FDA labeled contraindication to fluconazole OR
• • The patient has serious infection caused by Scedosporium or Fusarium species OR
• • The patient has another FDA labeled indication for the agent and route OR
• • The patient has another indication supported in compendia for the agent and route AND
• If FDA labeled indication: patient's age within labeling OR supported for use, AND no FDA labeled contraindications

Reauthorization criteria

• 1. The patient has been previously approved for Vfend through prior authorization AND
• 2. ONE of the following:
• • The patient has a diagnosis of invasive aspergillosis; serious infection caused by Scedosporium or Fusarium species; esophageal candidiasis; candidemia; or other deep tissue Candida infection, OR
• • The patient has another diagnosis and there is support for continued use of the requested agent for the requested indication

Approval duration

6 months (standard); BCBSNM: 3 months for esophageal candidiasis, 6 months for others; others: 1 month for esophageal candidiasis, 6 months for others; 12 months (Ohio Fully Insured or HIM Shop)