CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

isavuconazole (Cresemba) — coverage criteria for invasive aspergillosis and invasive mucormycosis

This policy governs prior authorization, quantity limits, and coverage duration for Cresemba (isavuconazole) capsules and injection for treatment of invasive aspergillosis or invasive mucormycosis for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policyisavuconazole (Cresemba) — coverage criteria for invasive aspergillosis and invasive mucormycosis

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for up to 3 months when all stated clinical criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 monthsauthorization duration

5/daycapsule limit 74.5 mg

2/daycapsule limit 186 mg

up to 2 daysloading dose exception

Coverage Criteria for Isavuconazole (Cresemba)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policyisavuconazole (Cresemba) — coverage criteria for invasive aspergillosis and invasive mucormycosis

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for up to 3 months when all stated clinical criteria are met.

SourceLink

On This Page

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Main approval conditions

Indication: Member is being treated for either invasive aspergillosis or invasive mucormycosis.
Age and formulation limits: Member is 1 year and older if the request is for Cresemba injection OR member is 6 years and older and weighs 16 kg or greater if the request is for Cresemba capsules.
Documentation and oversight
- Clinical and laboratory documentation identifying causative organism(s).
- Member is under the care of an infectious disease specialist.
Prior therapy / inpatient exception
- Member has failed an adequate dose and duration of voriconazole due to inadequate outcome and/or intolerance.
- Member is continuing Cresemba therapy initiated as an inpatient in a hospital setting.

Requests for isavuconazole that are for indications other than invasive aspergillosis or invasive mucormycosis are not supported by these criteria. Coverage also requires documentation of the causative organism(s) and that the member is under the care of an infectious disease specialist; absence of these items may result in denial. Additionally, when applicable, the member must have failed an adequate dose and duration of voriconazole for inadequate outcome and/or intolerance unless the request is for continuation of Cresemba therapy that was initiated during an inpatient hospitalization.

Provider Requirements and Prior Authorization

Prior Authorization

Prior authorization — up to 3 months

Prior authorization may be granted for up to 3 months when all stated clinical criteria are met; authorization duration is 3 months for initial therapy.

Step Therapy

Step therapy — voriconazole failure required

Member must have failed an adequate dose and duration of voriconazole for inadequate outcome and/or intolerance before outpatient initiation of Cresemba, unless the request is to continue Cresemba therapy that was initiated as an inpatient.

Documentation Required

Required documentation — clinical, lab, and specialist records

Provide clinical and laboratory documentation identifying the causative organism(s), and documentation that the member is under the care of an infectious disease specialist; include records showing prior voriconazole treatment failure or intolerance when applicable.

Clinical & laboratory documentation of causative organism(s)
Evidence that member is under care of an infectious disease specialist
Records of prior voriconazole dose/duration and failure or intolerance when required

Denial Risk

Denial triggers — missing indication or documentation

Requests may be denied if they do not document treatment for invasive aspergillosis or invasive mucormycosis, lack clinical and laboratory documentation of causative organism(s), do not show infectious disease specialist involvement, or do not demonstrate prior voriconazole failure when applicable.

Background

Isavuconazole (Cresemba) is an antifungal agent used in the treatment of invasive aspergillosis and invasive mucormycosis. This policy governs prior authorization, quantity limits, and initial coverage duration for Cresemba capsules and injection. Prior authorization may be granted for up to 3 months when all stated clinical criteria are met, including indication, age/weight limits for the formulation requested, organism documentation, infectious disease specialist involvement, and either prior failure/intolerance to an adequate course of voriconazole or continuation of inpatient‑initiated Cresemba therapy.

Cresemba 74.5mg capsules	quantity limit 5 capsules per day
Cresemba 186mg capsules	quantity limit 2 capsules per day

OpenPayer

isavuconazole (Cresemba) — coverage criteria for invasive aspergillosis and invasive mucormycosis

Coverage Criteria for Isavuconazole (Cresemba)

Quantity Limits and Coding

Provider Requirements and Prior Authorization

Covered Indications

Background