Medical Policy
Effective Date:01/01/2016 Title:Cresemba (Isavuconazonium)
Revision Date:01/01/2016 Document:BI488:00
CPT Code(s):C9456, J1833
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Cresemba (Isavuconazonium) requires prior authorization.

2)    Cresemba is used to treat invasive aspergillosis and invasive Mucormycosis.

3)    Cresemba capsules are covered under the pharmacy benefit as a specialty drug.

4)    Cresemba powder for injection is covered under the medical benefit.
Medical Statement

Cresemba (Isavuconazonium) is considered medically necessary when the following criteria are met:

1)    Clinically documented invasive Mucormycosis (B46.0 – B46.5) OR

2)    Clinically documented invasive Aspergillosis (B44.0 – B44.9) for which member has either failed or is intolerant to Voriconazol

 

Codes Used In This BI:

 

C9456                        Injection, Isavuconazonium sulfate, 1mg (deleted 1/1/2016)

J1833 Injection, Isavuconazonium sulfate, 1mg
Limits

As a specialty drug, Cresemba is limited to a maximum 30 day supply per fill under the pharmacy benefit.
Reference

1.    Cresemba Prescribing Information.  Astellas Pharma US, Inc. Northbrook, IL. April 2015.

2.    Clinical Pharmacology.  Accessed online 9/10/2015.

3.    Maertens J, Patterson J, Rahav G et al. A Phase 3 randomized, double-blind trial evaluating Isavuconazole vs. Voriconazol for the primary treatment of invasive fungal disease caused by Aspergillus spp. or other filamentous fungi (SECURE). Proceedings of the 24th European Society of Clinical Microbiology and Infectious Diseases. May 10 – 13, 2014, Barcelona, Madrid [Abstract #O230a].
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.