CurrentCignaPolicy N/A

Antifungals - Posaconazole (Oral) Prior Authorization Policy

Cigna prior authorization policy governing coverage and approval criteria for oral posaconazole (Noxafil and generics) for prescription benefit plans administered by Cigna companies; applies to clinicians requesting coverage for indicated and supported off-label uses.

Policy Summary

PayerCigna

PolicyAntifungals - Posaconazole (Oral) Prior Authorization Policy

Policy CodePolicy N/A

Change TypeTitle update and multiple approval-duration changes

Effective DateN/A

Next Review DateJul 16, 2025

Key ActionSubmit prior authorization requests with appropriate billing and diagnosis codes and supporting clinical information to demonstrate the patient meets the policy criteria.

SourceLink

POLICY UPDATE CHANGES

Policy name changed from 'Antifungals - Noxafil (Oral) PA' to 'Antifungals - Posaconazole (Oral) PA.'

Added 'Fungal Infection (Systemic) in a Patient with Graft-versus-Host Disease - Prophylaxis' as a condition of approval.

Changed duration of approval for Aspergillus infection - Treatment to 6 months (previously 3 months).

Changed duration of approval for mucormycosis - Maintenance Treatment to 12 months (previously 6 months).

Changed duration of approval for fungal infection in a patient with HIV - Treatment to 6 months (previously 3 months) and removed example conditions from that item.

Noxafilproducts covered (tablets, suspension, PowderMix)

15approved conditions listed

6 mocommon approval duration

Policy Summary

PayerCigna

PolicyAntifungals - Posaconazole (Oral) Prior Authorization Policy

Policy CodePolicy N/A

Change TypeTitle update and multiple approval-duration changes

Effective DateN/A

Next Review DateJul 16, 2025

Key ActionSubmit prior authorization requests with appropriate billing and diagnosis codes and supporting clinical information to demonstrate the patient meets the policy criteria.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Approval Criteria

Criteria for medical necessity (approved indications and supported uses)

Covered when ANY of the following FDA‑approved or supported‑by‑evidence indications are met (each with the specified approval duration).

FDA‑approved indications: 1. Aspergillus Infection - Prophylaxis. Approve for 6 months.

FDA‑approved indications: 2. Aspergillus Infection - Treatment. Approve for 6 months.

FDA‑approved indications: 3. Candida Infection (Systemic) - Prophylaxis. Approve for 6 months.

FDA‑approved indications: 4. Oropharyngeal Candidiasis - Treatment. Approve for 3 months.

Other uses with supportive evidence: 5. Esophageal Candidiasis in a Patient with Human Immunodeficiency Virus (HIV) Infection - Chronic Suppressive Treatment. Approve for 6 months.

Other uses with supportive evidence: 6. Fungal Infection (Systemic) in a Patient With Cancer and Neutropenia - Prophylaxis. Approve for 6 months. Note: examples of cancers predisposing to neutropenia include myelodysplastic syndrome, acute myeloid leukemia, and post‑allogeneic hematopoietic cell transplant.

Other uses with supportive evidence: 7. Fungal Infection (Systemic) in a Patient with Graft‑versus‑Host Disease - Prophylaxis. Approve for 6 months.

Other uses with supportive evidence: 8. Fungal Infection (Systemic) in a Patient with Human Immunodeficiency Virus Infection - Treatment. Approve for 6 months.

Other uses with supportive evidence: 9. Fusariosis, Invasive - Treatment. Approve for 3 months.

Other uses with supportive evidence: 10. Mouth and Esophageal Infection (Refractory to Other Azole Antifungals) - Treatment. Approve for 3 months.

Other uses with supportive evidence: 11. Mucormycosis - Maintenance Treatment. Approve for 12 months.

Other uses with supportive evidence: 12. Scedosporium Infection - Treatment. Approve for 3 months.

Other uses with supportive evidence: 13. Fungal Infection (Systemic) that is Susceptible to Posaconazole - Treatment. Approve for 3 months.

Other uses with supportive evidence: 14. Cryptococcal Meningitis - Treatment. Approve for 12 months.

Other uses with supportive evidence: 15. Patient is Currently Receiving Posaconazole - Approve for 3 months to complete the course of therapy.

Posaconazole (oral formulations: delayed-release tablets, oral suspension, and PowderMix for delayed-release oral suspension) is not medically necessary for any uses not explicitly listed in this policy. Operational updates to the policy may occur as new published data become available; coverage determinations will be revised accordingly.

Any clinical use or indication for oral posaconazole that is not specifically enumerated in the policy’s approved indications and supported-use list should be considered not medically necessary. Providers should include supporting clinical evidence if requesting coverage for an indication not listed, recognizing the policy will be updated only when new published evidence justifies a change.

Products, Age/Weight Limits, and Coding

Covered NDC / ProductsNDCCovered

Noxafil (posaconazole) delayed-release tablets - Merck	NDCs vary by package — delayed-release tablets (posaconazole) marketed as Noxafil and generics
Noxafil (posaconazole) oral suspension - Merck	NDCs vary by package — oral suspension (posaconazole) marketed as Noxafil and generics
Noxafil PowderMix for delayed-release oral suspension - Merck	NDCs vary by package — PowderMix for delayed-release oral suspension (posaconazole) marketed as Noxafil

Pediatric age/weight thresholds — formulation-specific (label = formulation, value = age/weight limits)

Delayed‑release tabletsAdults and pediatric patients ≥ 13 years of age for treatment of invasive aspergillosis; prophylaxis in adults and pediatric patients ≥ 2 years of age who weigh > 40 kg

Oral suspensionAdults and pediatric patients ≥ 13 years of age for prophylaxis; oropharyngeal candidiasis treatment in patients ≥ 13 years

PowderMix for delayed‑release oral suspensionPediatric patients ≥ 2 years of age who weigh ≤ 40 kg for prophylaxis

Provider Requirements, Prior Authorization, and Billing

Prior Authorization

Prior Authorization Required

Prior authorization required. Prescription benefit coverage for Noxafil/posaconazole (oral formulations) requires prior authorization. Approvals are provided for the durations noted in the policy (months = 30 days).

A prior authorization request must specify the FDA‑approved or supported indication and desired approval duration.
Typical approval durations: 3, 6, or 12 months depending on indication as listed in the policy.

Note

Refractory Oropharyngeal/Esophageal Candidiasis

Refractory oropharyngeal candidiasis. For oropharyngeal or esophageal candidiasis that is refractory to first‑line azoles (fluconazole or itraconazole), posaconazole oral suspension may be considered. Requests should document prior intolerance or therapeutic failure with fluconazole and/or itraconazole.

Include evidence of prior treatment attempts (dates, doses, duration) and clinical response.
If patient has HIV or other immunocompromising condition, include relevant CD4 counts, viral load, or immunosuppression details when available.

Definitions and Indication Notes

Prophylaxis — definition and context

DefinitionProphylaxis of invasive Aspergillus and Candida infections in patients at high risk due to severe immunocompromise (e.g., HSCT recipients with graft‑versus‑host disease or patients with hematologic malignancies with prolonged neutropenia)

Typical formulations for prophylaxisDelayed‑release tablets (adults and pediatric ≥ 2 years who weigh > 40 kg); oral suspension (adults and pediatric ≥ 13 years); PowderMix delayed‑release oral suspension (pediatric ≥ 2 years who weigh ≤ 40 kg)

Clinical considerationsDuration of prophylaxis varies based on recovery from neutropenia, degree of immunosuppression, and clinical response (study mean duration ~80 days)

Background and Clinical Context

Posaconazole is an azole antifungal agent used to prevent and treat invasive fungal infections. It is commonly used for prophylaxis against invasive Aspergillus and Candida infections in high‑risk, severely immunocompromised patients and for the treatment of a variety of invasive fungal infections. Recommended durations of therapy vary by indication.