TOBI Podhaler — CareFirst (Caremark)
Non-cystic fibrosis bronchiectasis with Pseudomonas aeruginosa
Initial criteria
- For cystic fibrosis: Member age ≥ 2 years AND Pseudomonas aeruginosa is present in airway cultures OR member has a history of Pseudomonas aeruginosa infection or colonization in the airways.
- For non-cystic fibrosis bronchiectasis: Pseudomonas aeruginosa is present in airway cultures OR member has a history of Pseudomonas aeruginosa infection or colonization in the airways.
Reauthorization criteria
- Member is requesting reauthorization for an indication listed in the coverage criteria section AND is experiencing benefit from therapy as evidenced by disease stability or disease improvement.
Approval duration
12 months