Tolsura (itraconazole) — Highmark
pulmonary or extrapulmonary blastomycosis
Preferred products
- generic itraconazole capsules
Initial criteria
- age ≥ 18 years
- Diagnosis of one of the following: pulmonary or extrapulmonary blastomycosis (ICD-10: B40) OR histoplasmosis including chronic cavitary pulmonary disease and disseminated, non-meningeal histoplasmosis (ICD-10: B39) OR pulmonary or extrapulmonary aspergillosis (ICD-10: B44)
- If diagnosis is aspergillosis, member has experienced therapeutic failure, contraindication, or intolerance to amphotericin B
- Member has experienced therapeutic failure, contraindication, or intolerance to generic, plan-preferred itraconazole capsules
Approval duration
12 months