Arikayce (amikacin) liposome inhalation suspension — Highmark

Initial criteria

• Diagnosis of Mycobacterium avium complex (MAC) lung disease (ICD-10: A31.0)
• Member did not achieve negative sputum cultures despite at least 6 consecutive months of treatment with a multidrug background regimen that has utilized at least two of the following agents: macrolide (e.g., clarithromycin or azithromycin), rifamycin (e.g., rifampin, rifabutin), or ethambutol
• Arikayce will continue to be used in conjunction with a background multidrug regimen

Reauthorization criteria

• Prescriber attests that additional therapy is needed as the member has experienced one of the following: positive sputum cultures OR negative sputum cultures for an insufficient period of time (e.g., less than 12 months)
• Arikayce will continue to be used in conjunction with a background multidrug regimen

Approval duration

12 months