CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Voriconazole prior authorization and coverage criteria

Covers prior authorization criteria and coverage duration for voriconazole for members of Neighborhood Health Plan of Rhode Island (Medicaid). Applies to patients meeting specified clinical diagnoses and age criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVoriconazole prior authorization and coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document patient age (>=2 years) plus a listed diagnosis and any required prior azole failure or clinical inappropriateness.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 yrsMinimum age

6 moCoverage duration

5Indication groups

MedicaidScope

Coverage Criteria for Voriconazole

Initial authorization criteria

Authorization may be granted when ALL of the following are met:

Age requirement: Patient is 2 years or older>=2 years

Age must be documented

Indication

Invasive aspergillus: Documented diagnosis of an invasive aspergillus infection
Scedosporium or Fusarium: Documented diagnosis of a serious infection caused by scedosporium or fusarium species

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVoriconazole prior authorization and coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document patient age (>=2 years) plus a listed diagnosis and any required prior azole failure or clinical inappropriateness.

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.

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for voriconazole. Approval is granted when all clinical criteria and the age requirement are met. Coverage duration when approved: 6 months.

Coverage duration: 6 months
Reviewed: 10/2021, 9/2022, 3/2023, 3/2024, 5/2025, 4/2026
Scope: Medicaid

Step Therapy

Step Therapy Requirements

Step therapy requirements apply for certain candidiasis and candidemia indications. For esophageal or oropharyngeal candidiasis, and for candidemia/disseminated candidiasis, there must be prior documented failure of, or clinical inappropriateness to, alternative antifungals as specified.

Esophageal or oropharyngeal candidiasis: documented failure of or clinical inappropriateness to fluconazole and itraconazole required
Candidemia and disseminated candidiasis: documented failure of or clinical inappropriateness to oral fluconazole required

Documentation Required

Required Documentation

Documentation must include patient age and a matching documented diagnosis. When step therapy is required, include documentation of prior antifungal failure or intolerance.

Patient age documented and >= 2 years
Documented diagnosis matching one of the listed indications: invasive aspergillus; serious infections due to Scedosporium or Fusarium; esophageal or oropharyngeal candidiasis; candidemia/disseminated candidiasis; or prevention of invasive aspergillus/candida in high-risk hematologic patients
When applicable, documentation of prior antifungal failure or clinical inappropriateness (per step therapy rules)

Denial Risk

Denial Triggers

Requests that do not meet the age requirement or that lack a covered diagnosis will be denied.

Requests for patients younger than 2 years will be denied
Requests without a documented diagnosis matching approved indications (see criteria) will be denied

Clinical Background

Voriconazole is an antifungal agent used for serious invasive fungal infections. The policy authorizes voriconazole when the member has one of several documented indications, including invasive aspergillus infection, serious infections caused by Scedosporium or Fusarium species, severe esophageal or oropharyngeal candidiasis (when there is documented failure of or clinical inappropriateness to fluconazole and itraconazole), candidemia or disseminated candidiasis (when there is documented failure of or clinical inappropriateness to oral fluconazole), or for prevention of invasive aspergillus and candida infections in patients with hematologic malignancy with neutropenia, hematopoietic stem cell transplant, or graft-versus-host disease.

Definitions and Special Populations

Prior failure or clinical inappropriateness

DefinitionDocumentation that fluconazole and/or itraconazole were ineffective, not tolerated, or otherwise clinically inappropriate for the patient, when required by the indication.

When requiredRequired for esophageal or oropharyngeal candidiasis (failure or inappropriateness to fluconazole and itraconazole).

Oral fluconazole specificRequired for candidemia and disseminated candidiasis when prior failure or clinical inappropriateness to oral fluconazole is documented.

Documentation sourceMust be included in the prior authorization request to demonstrate prior therapeutic trial or contraindication as stated in the criteria for approval.

Prophylaxis population

DefinitionPatients intended to receive prophylactic voriconazole against invasive aspergillus and candida infections who have hematologic malignancy with neutropenia, are hematopoietic stem cell transplant recipients, or have graft-versus-host disease.

Required documentationDocumentation of the hematologic malignancy with neutropenia, hematopoietic stem cell transplant status, or graft-versus-host disease must be provided with the request.

Indication contextProphylaxis is listed as one of the approved indications meeting the criteria for authorization when the above conditions are documented.