Voriconazole

Criteria for Approval (Initial Therapy)

Criteria for Approval

An authorization may be granted when all the following criteria are met:

ALL of the following

ONE of the following diagnoses/indications
- Patient is 2 years or older
- Patient has documented diagnosis of an invasive aspergillus infection
- Patient has documented diagnosis of a serious infection caused by scedosporium and fusarium species
- Patient has documented diagnosis of esophageal candidiasis or oropharyngeal candidiasis
  Requires documented failure of or clinical inappropriateness to fluconazole and itraconazole
- Patient has documented diagnosis of candidemia and disseminated candidiasis infections
  Requires documented failure of or clinical inappropriateness to oral fluconazole
- Documented diagnosis of prevention of invasive aspergillus and candida fungal infections
  Requires documentation of hematologic malignancy with neutropenia, hematopoietic stem cell transplant, or graft-versus-host disease

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OpenPayer

Coverage Summary

Criteria for Approval (Initial Therapy)

Provider Actions & Authorization Requirements

Applicable Codes

Clinical Evidence & Rationale

Background

Revision History