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Vfend (voriconazole) — Blue Cross Blue Shield of Texas

invasive aspergillosis

Preferred products

  • fluconazole

Initial criteria

  • ALL of the following:
  • 1. ONE of the following:
  • A. Diagnosis of invasive aspergillosis OR
  • B. BOTH of the following:
  • 1. Requested agent prescribed for prophylaxis of invasive aspergillosis or Candida AND
  • 2. Patient is severely immunocompromised (e.g., HSCT, hematologic malignancy with prolonged neutropenia, or high-risk solid organ transplant recipient) OR
  • C. Diagnosis of esophageal candidiasis, candidemia, or other deep tissue Candida infection AND ONE of the following:
  • 1. BOTH of the following:
  • A. ONE of the following:
  • 1. Patient has stage IV advanced metastatic cancer and requested agent treats the cancer OR
  • 2. Patient has stage IV advanced metastatic cancer and requested agent treats an associated condition AND
  • B. Use is consistent with best practices, supported by evidence-based literature, and FDA approved OR
  • 2. Tried and had inadequate response to fluconazole OR
  • 3. Intolerance or hypersensitivity to fluconazole OR
  • 4. FDA labeled contraindication to fluconazole OR
  • D. Serious infection caused by Scedosporium or Fusarium species OR
  • E. Another FDA labeled indication for the requested agent and route OR
  • F. Another indication supported in compendia (AHFS or DrugDex 1, 2a, 2b) AND both: age appropriate or support for use, and no FDA labeled contraindication
  • 2. Patient has no FDA labeled contraindication

Reauthorization criteria

  • ALL of the following:
  • 1. Patient previously approved for requested agent through plan’s PA process
  • 2. ONE of the following:
  • A. BOTH of the following:
  • 1. Diagnosis of invasive aspergillosis, serious infection caused by Scedosporium or Fusarium species, esophageal candidiasis, candidemia, or other deep tissue Candida infection AND
  • 2. Continued indicators of active disease (biomarkers, biopsy, culture, radiographic evidence) OR
  • B. BOTH of the following:
  • 1. Diagnosis other than above AND
  • 2. Support for continued use for requested indication

Approval duration

6 months (BCBSIL/BCBSMT and BCBSNM other indications), 3 months (BCBSNM esophageal candidiasis), 1 month (others for esophageal candidiasis), 12 months (Ohio fully insured/HIM Shop)