CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Itraconazole Sporanox Oral Solution Pa Policy 210 A 03 2023

This policy defines prior authorization coverage criteria for Sporanox (itraconazole) Oral Solution for treatment of oropharyngeal and esophageal candidiasis under Neighborhood Health Plan of Rhode Island (CVS Caremark criteria). It specifies clinical prerequisites (failure, intolerance, or contraindication to fluconazole).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyItraconazole Sporanox Oral Solution Pa Policy 210 A 03 2023

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required for Sporanox (itraconazole) Oral Solution; provider must document indication (oropharyngeal or esophageal candidiasis) and either inadequate response to, intolerance to, or contraindication to fluconazole.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage criteria or policy content.

2Covered Indications

1Required prior step (fluconazole)

Coverage Summary

Coverage stance: covered_with_criteria.

Scope summary: This policy defines prior authorization coverage criteria for Sporanox (itraconazole) Oral Solution for treatment of oropharyngeal and esophageal candidiasis under Neighborhood Health Plan of Rhode Island (CVS Caremark criteria). It specifies clinical prerequisites requiring prior authorization and documentation of either treatment failure, intolerance, or a contraindication to fluconazole before Sporanox oral solution is authorized.