CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Voriconazole (Vfend) prior authorization for serious fungal infections

Defines authorization criteria for voriconazole (Vfend) for treatment or prophylaxis of specified serious fungal infections for prescribers seeking payer approval.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVoriconazole (Vfend) prior authorization for serious fungal infections

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document required clinical information, including cultures and prior trial or intolerance to alternative antifungal therapy when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsDuration of approval (DOA)

>=2 yrsApproved patient age

241-AReference

Coverage Criteria for Voriconazole (Vfend)

Aspergillosis, Scedosporiosis, Fusariosis and related

Authorization may be granted when ALL of the following are met for listed aspergillosis and related indications:

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVoriconazole (Vfend) prior authorization for serious fungal infections

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document required clinical information, including cultures and prior trial or intolerance to alternative antifungal therapy when required.

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.

Aspergillosis and related indications: The requested drug is being prescribed for ANY of the following: serious fungal infection caused by Scedosporium apiospermum and Fusarium species; treatment of invasive aspergillosis (including invasive pulmonary aspergillosis); prophylaxis of invasive aspergillosis in a high-risk patient; empiric antifungal therapy for febrile neutropenia in a high-risk patient; chronic pulmonary aspergillosis; mycosis due to Scedosporium prolificans; fungal peritoneal dialysis-associated peritonitis.

Patient will use the requested drug orally or intravenously; if request is for voriconazole powder for oral suspension, patient must have difficulty swallowing solid oral dosage forms or require a dose not available in commercially available tablets.

Candidemia, other Candida infections, and Talaromycosis

Authorization may be granted when ALL of the following are met for Candida infections and talaromycosis:

Candida and talaromycosis indications: Patient has candidemia in a non-neutropenic patient OR the requested drug is being prescribed for ANY of the following: disseminated Candida infection in the skin; esophageal candidiasis; Candida infection in the abdomen, kidney or bladder wall, or wounds; oropharyngeal candidiasis; or talaromycosis. AND the patient has experienced an inadequate treatment response to an alternative antifungal therapy. AND the patient meets ONE of: the patient has experienced an intolerance to an alternative antifungal therapy; the patient will use the requested drug orally or intravenously; or the patient has a contraindication that would prohibit a trial of an alternative antifungal therapy. AND if the request is for voriconazole powder for oral suspension, the patient meets ONE of the following: has difficulty swallowing solid oral dosage forms (e.g., tablets) or requires a dose that cannot be obtained using the commercially available tablets.

Step therapy requirement: inadequate response or intolerance to alternatives unless contraindicated.

Requests that do not include documentation showing that all applicable policy criteria are met will be considered not meeting medical necessity. Examples include lack of documentation of an indicated diagnosis that appears in the policy, absence of required documentation of an inadequate response or intolerance to an alternative antifungal when step-therapy is required, or missing information on the intended route of administration (oral or intravenous) when that is a condition of coverage.

Provider Actions, Requirements, and Determinations

Prior Authorization

Prior Authorization Required

Prior authorization is required. Authorization may be granted when ALL listed criteria for the requested indication are met. Approved duration of authorization is 6 months (Reference 241-A).

Applies to requests for oral or intravenous use
Includes voriconazole powder for oral suspension when patient has difficulty swallowing tablets or requires an unavailable tablet dose

Denial Risk

Denial Triggers for Unmet Criteria

Requests that do not meet ALL of the policy's criteria for the indicated infection(s) will be denied. Examples of unmet criteria include but are not limited to: the medication is requested for an infection not listed in the policy (e.g., not one of the specified serious fungal infections, candidiasis, or talaromycosis); the patient is not planned to use the medication by an oral or intravenous route as required; or required documentation (including evidence of prior inadequate response/intolerance to alternative antifungal therapy when applicable) is missing.

Denial triggers: indication not listed in policy
Denial triggers: route of administration not oral or IV
Denial triggers: missing documentation of prior treatment failure or intolerance where required (candida/talaromycosis)
Denial triggers: lack of clinical justification or absent laboratory/culture documentation when relevant

Documentation Required

Required Clinical Documentation

Obtain specimens for fungal culture and other relevant laboratory studies (including histopathology) prior to initiating therapy when feasible. Therapy may begin before results are available, but once results return, antifungal therapy should be adjusted accordingly.

Collect and document specimens to isolate and identify causative organism(s) prior to therapy whenever possible

Background on Voriconazole

Voriconazole is an antifungal agent used for treatment or prophylaxis of serious fungal infections. Within this policy, it is addressed for indications including invasive aspergillosis (including invasive pulmonary aspergillosis), prophylaxis of invasive aspergillosis in high-risk patients, empiric therapy for febrile neutropenia in high-risk patients, chronic pulmonary aspergillosis, infections due to Scedosporium and Fusarium species, fungal peritoneal dialysis–associated peritonitis, and a range of Candida infections and talaromycosis. When applicable, the policy requires documentation of cultures or other clinical evidence and specifies that the patient will use the drug orally or intravenously; requests for the oral suspension formulation require demonstration of difficulty swallowing tablets or need for a non‑tablet dose.

Definitions and Clinical Terms

Invasive Aspergillosis — Definition and age applicability (>= 2 years)

DefinitionInvasive aspergillosis (IA): a serious fungal infection for which voriconazole (Vfend) is indicated in adults and pediatric patients 2 years of age and older; most clinical isolates are Aspergillus fumigatus, with fewer cases due to other Aspergillus species.

Approved patient age>= 2 years (adults and pediatric patients)

Typical pathogensMost isolates recovered in trials were Aspergillus fumigatus; other Aspergillus species may cause IA.

Notes on useVoriconazole may be used for treatment of invasive pulmonary aspergillosis and other invasive aspergillosis presentations as described in the policy.

Candidemia and deep tissue Candida infections — Definition and clinical scope

DefinitionCandidemia in non-neutropenic patients and other deep tissue Candida infections: includes disseminated skin infections and Candida infections of the abdomen, kidney, bladder wall, and wounds; voriconazole is indicated in adults and pediatric patients 2 years of age and older.

Approved patient age>= 2 years (adults and pediatric patients)

Clinical scopeCandidemia (non-neutropenic) and deep tissue/disseminated Candida infections affecting skin, abdominal organs, urinary tract wall (kidney/bladder), and wounds.

Notes on usePolicy requires documented indication matching the listed Candida infections and, where applicable, prior inadequate response or intolerance to alternative antifungal therapy per coverage criteria.