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Tobi — Highmark

cystic fibrosis (CF) with Pseudomonas aeruginosa colonization

Preferred products

  • generic tobramycin inhalation solution

Initial criteria

  • Diagnosis of cystic fibrosis (ICD-10: E84)
  • Member is colonized with Pseudomonas aeruginosa
  • If request is for brand Tobi inhalation solution, member has experienced therapeutic failure or intolerance to generic tobramycin inhalation solution
  • If request is for brand Bethkis 300 mg/4 mL inhalation solution, Kitabis Pak, or Tobi Podhaler, member has experienced therapeutic failure or intolerance to plan-preferred, generic tobramycin inhalation solution

Reauthorization criteria

  • Prescriber attests that the member experienced a decrease in sputum density of Pseudomonas aeruginosa
  • OR prescriber attests that the member experienced an increase in FEV1
  • OR prescriber attests that the member experienced a decrease in the number of hospitalizations
  • OR prescriber attests that the member experienced a decrease in the number of pulmonary exacerbations

Approval duration

up to 24 months