Arikayce — Medical Mutual

Initial criteria

• Patient age > 18 years
• Patient has completed ≥ 6 consecutive months of a background multidrug regimen
• Patient has a positive sputum culture for Mycobacterium avium complex
• Culture was collected within the past 3 months AND after ≥ 6 months of background multidrug regimen
• Mycobacterium avium complex isolate is susceptible to amikacin
• Arikayce will be used in conjunction with a background multidrug regimen
• Medication is prescribed by a pulmonologist, infectious diseases physician, or a physician who specializes in the treatment of Mycobacterium avium complex lung infections

Reauthorization criteria

• Arikayce will be used in conjunction with a background multidrug regimen
• Patient has not achieved negative sputum cultures for Mycobacterium avium complex OR patient has achieved negative sputum cultures for less than 12 months (approve enough Arikayce to complete 12 months of therapy following a negative sputum culture)

Approval duration

1 year