Vfend (voriconazole) — Blue Cross Blue Shield of Texas

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)