Arikayce (amikacin liposome inhalation suspension) — United Healthcare

Initial criteria

• Diagnosis of Mycobacterium avium complex (MAC) lung disease
• Patient has not achieved negative sputum cultures after a minimum of 6 consecutive months of a multidrug background regimen therapy (e.g. macrolide, rifampin, and ethambutol) within the past 12 months
• Patient has limited or no alternative treatment options
• Used as part of a combination antibacterial drug regimen

Reauthorization criteria

• Patient has achieved negative sputum cultures

Approval duration

Initial: 6 months; Reauthorization: 12 months