CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Sporanox (itraconazole) oral solution prior authorization — oropharyngeal and esophageal candidiasis

Defines prior authorization coverage criteria for Sporanox (itraconazole) oral solution for treatment of oropharyngeal or esophageal candidiasis for the payer's beneficiaries.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySporanox (itraconazole) oral solution prior authorization — oropharyngeal and esophageal candidiasis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document oropharyngeal or esophageal candidiasis plus inadequate response, intolerance, or contraindication to fluconazole.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2FDA-approved indications listed

1Prior authorization type

4References cited

3Clinical pathways

Coverage Criteria for Sporanox (itraconazole) Oral Solution

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Initial Authorization Criteria

Covered when ALL of the following are met:

Indication: The requested drug is being prescribed for the treatment of oropharyngeal candidiasis or esophageal candidiasis

Support with diagnosis documentation

Fluconazole pathway: Patient has experienced an inadequate treatment response to fluconazole OR has an intolerance to fluconazole OR has a contraindication that would prohibit a trial of fluconazole

At least one of these must be documented; represents step therapy exception

Provider Requirements and Prior Authorization Process

Prior Authorization

Prior Authorization Required

Prior authorization is required. Coverage is approved when the drug is prescribed for oropharyngeal candidiasis or esophageal candidiasis and the patient meets the step-therapy or intolerance/contraindication criteria described below.

Affected drug: Sporanox (itraconazole) oral solution

Step Therapy

Step Therapy with Fluconazole

Step therapy: A trial of fluconazole is required prior to approval of Sporanox oral solution unless there is documented intolerance or a contraindication to fluconazole.

Acceptable alternatives to step trial: documented intolerance to fluconazole or a documented contraindication preventing fluconazole use

Documentation Required

Required Documentation

Documentation must show the drug is prescribed for oropharyngeal candidiasis or esophageal candidiasis and provide evidence of either an inadequate response to fluconazole, intolerance to fluconazole, or a contraindication to fluconazole.

Required documentation: diagnosis (oropharyngeal or esophageal candidiasis) and clinical justification for use (inadequate response, intolerance, or contraindication to fluconazole)

Denial Risk

Denial Risk for Missing Criteria

Requests that do not document both the treated diagnosis (oropharyngeal or esophageal candidiasis) and either a trial of fluconazole (with inadequate response) or a documented intolerance/contraindication to fluconazole are at risk for denial.

Denial risk applies when: diagnosis is missing or not one of the covered indications, or there is no documentation of fluconazole trial, intolerance, or contraindication

Background

Itraconazole oral solution (Sporanox) is recognized in this policy for treatment of oropharyngeal and esophageal candidiasis. Prior authorization is required, and coverage is approved only when the medication is prescribed for one of these indications and the member has either an inadequate treatment response to fluconazole, documented intolerance to fluconazole, or a contraindication to fluconazole that would prohibit a trial.