Arikayce (amikacin liposome inhalation suspension) — CareFirst (Caremark)

Initial criteria

• Patient has refractory Mycobacterium avium complex (MAC) lung disease with limited or no other treatment options.
• Requested medication will be used as part of a combination antibacterial drug regimen.
• Patient has not achieved negative sputum cultures after being treated with a multidrug background regimen therapy for a minimum of 6 consecutive months.

Reauthorization criteria

• Member is experiencing benefit from therapy as evidenced by disease stability or disease improvement (e.g., achievement and maintenance of negative sputum cultures).

Approval duration

12 months