CurrentNeighborhood Health Plan of Rhode IslandPolicy Vfend Pa Policy 241 A 01 2022

Vfend Pa Policy 241 A 01 2022

Prior authorization criteria for VFEND (voriconazole) covering indications (treatment and prophylaxis) including invasive aspergillosis, candidemia and other deep tissue Candida infections, esophageal/oropharyngeal candidiasis, Scedosporium/Fusarium infections, and certain compendial uses. Specifies requirement for prior trial/intolerance/contraindication to alternative antifungal therapy and formulation-specific criteria for oral suspension.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVfend Pa Policy 241 A 01 2022

Policy CodePolicy Vfend Pa Policy 241 A 01 2022

Change Typeclarified

Effective Date

Next Review Date

Key ActionPrior authorization is required and VFEND will be covered only when the specified indication criteria and trial/intolerance/contraindication to alternative antifungal therapy are documented, and route of administration (oral or IV) is specified.

SourceLink

POLICY UPDATE CHANGES

Policy text reflects CVS Caremark criteria and 2021 Vfend package insert references.

11Covered Indications Listed

covered_with_criteriaCoverage Stance

Coverage Summary

Vfend (voriconazole) is covered with criteria (coverage_stance = covered_with_criteria) per policy Vfend Pa Policy 241 A 01 2022. Coverage is allowed when the requested use meets specified indications including: invasive aspergillosis (including invasive pulmonary aspergillosis), candidemia in non-neutropenic patients and other deep tissue Candida infections, Scedosporium apiospermum and Fusarium species infections, prophylaxis of invasive aspergillosis in high-risk patients, empiric antifungal therapy for febrile neutropenia in high-risk patients, chronic pulmonary aspergillosis, and oropharyngeal and esophageal candidiasis. The policy requires documentation of an inadequate response to, intolerance of, or contraindication to alternative antifungal therapy and specifies formulation-based criteria for voriconazole oral suspension.

VFEND Summary

PolicyVfend Pa Policy 241 A 01 2022

PayerCVS Caremark

Coverage StanceCovered with criteria

Scope SummaryPrior authorization criteria for VFEND (voriconazole) covering treatment and prophylaxis of invasive aspergillosis, candidemia and other deep tissue Candida infections, esophageal/oropharyngeal candidiasis, Scedosporium and Fusarium infections, empiric therapy for febrile neutropenia in high-risk patients, and compendial uses; requires trial/intolerance/contraindication to alternative antifungal and formulation-specific justification for oral suspension.

Initial Therapy Criteria (Prior Authorization)

Initial Prior Authorization / Medically Necessary

Covered when the following logical combinations are met:

Indication (ANY of the following)

Treatment of invasive aspergillosis (including invasive pulmonary aspergillosis) in adults and pediatric patients 2 years of age and older
Serious fungal infection caused by Scedosporium apiospermum and Fusarium species (including Fusarium solani), in adults and pediatric patients 2 years of age and older
Prophylaxis of invasive aspergillosis in a high-risk patient
Chronic pulmonary aspergillosis
Empiric antifungal therapy for febrile neutropenia in a high-risk patient
Mycosis due to Scedosporium prolificans
Candidemia in a non-neutropenic patient
Disseminated Candida infection in the skin
Candida infection in the abdomen, kidney, bladder wall, or wounds
Esophageal candidiasis
Oropharyngeal candidiasis

ALL of the following

Patient has experienced an inadequate treatment response to an alternative antifungal therapy
Patient has experienced an intolerance to an alternative antifungal therapy
Patient has a contraindication that would prohibit a trial of an alternative antifungal therapy

ALL of the following

If request is for voriconazole powder for oral suspension, ONE of the following must be met
- Patient has difficulty swallowing solid oral dosage forms (e.g., tablets)
- Patient requires a dose that cannot be obtained using the commercially available tablets

Provider Actions

Prior Authorization

Prior authorization required

Prior authorization is required. VFEND (voriconazole) will be covered only when the specified indication criteria are met and when documentation shows a trial with, intolerance to, or contraindication to an alternative antifungal therapy. The route of administration (oral or IV) must be specified.

Documentation Required

Document intolerance/contraindication or inadequate response

Provider must document either an inadequate response to an alternative antifungal therapy, intolerance to an alternative antifungal therapy, or a contraindication that would prohibit a trial of an alternative antifungal therapy.

Documentation Required

Formulation justification for oral suspension

If requesting voriconazole powder for oral suspension, the provider must document either difficulty swallowing solid oral dosage forms (e.g., tablets) or a requirement for a dose that cannot be obtained using the commercially available tablets.

Clinical Evidence & References

Primary product reference: Vfend package insert, Pfizer, January 2021. Voriconazole is indicated for multiple serious fungal infections including invasive aspergillosis, candidemia and other deep tissue Candida infections, and serious infections due to Scedosporium and Fusarium species. Specimens for fungal culture and other relevant laboratory studies (including histopathology) should be obtained prior to initiating therapy, and therapy should be adjusted based on culture and laboratory results when available.

Background

Indications overview: Vfend (voriconazole) is indicated for invasive aspergillosis in adults and pediatric patients 2 years and older, candidemia in non-neutropenic patients and certain deep-tissue Candida infections, esophageal and oropharyngeal candidiasis, serious infections due to Scedosporium apiospermum and Fusarium species (including Fusarium solani), and compendial uses such as empiric antifungal therapy for febrile neutropenia and prophylaxis of invasive aspergillosis in high-risk patients.

Recommended specimen collection and labs: obtain specimens for fungal culture and other relevant laboratory studies (including histopathology) prior to therapy to isolate and identify causative organisms.

Clinical management note: therapy may be initiated empirically before culture results are available, but antifungal therapy should be adjusted accordingly once culture and laboratory results are known.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVfend Pa Policy 241 A 01 2022

Policy CodePolicy Vfend Pa Policy 241 A 01 2022

Change Typeclarified

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Vfend Pa Policy 241 A 01 2022

Coverage Summary

Initial Therapy Criteria (Prior Authorization)

Provider Actions

Applicable Codes

Clinical Evidence & References

Background

Revision History