Vivjoa (oteseconazole) — Blue Cross Blue Shield of Texas

Initial criteria

• ONE of the following:
• A. ALL of the following:
• 1. The patient has a diagnosis of recurrent vulvovaginal candidiasis (RVVC)
• 2. The patient has experienced ≥ 2 episodes of vulvovaginal candidiasis within a 12 month period
• 3. ONE of the following:
• A. BOTH of the following:
• 1. ONE of the following:
• A. The patient has been diagnosed with stage 4 advanced, metastatic cancer and the requested agent is being used to treat the cancer OR
• B. The patient has been diagnosed with stage 4 advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage 4 advanced metastatic cancer [chart notes required]
• 2. The use of the requested agent is consistent with best practices for the treatment of stage 4 advanced, metastatic cancer, or an 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
• B. The patient has another FDA labeled indication for the requested agent and route of administration OR
• C. The patient has another indication that is supported in compendia for the requested agent and route of administration
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

BCBSIL and BCBSMT: 6 months; all other plans: RVVC 4 months, other indications 6 months