tobramycin solution for inhalation — United Healthcare
noncystic fibrosis bronchiectasis with recurrent exacerbations and Pseudomonas aeruginosa infection
Initial criteria
- One of the following:
- Diagnosis of cystic fibrosis (CF)
- OR
- Both of the following:
- Diagnosis of noncystic fibrosis bronchiectasis
- AND
- One of the following:
- Three or more exacerbations per year
- OR
- Two or more exacerbations requiring hospitalization per year
- AND
- Lung infection with positive culture demonstrating Pseudomonas aeruginosa infection
Reauthorization criteria
- Documentation of positive clinical response to Bethkis, Kitabis Pak, TOBI Nebulizer Solution, TOBI Podhaler, or tobramycin solution for inhalation therapy
Approval duration
12 months