Prior Authorization Criteria for Approval

Initial Evaluation

Cresemba will be approved when BOTH of the following are met:

1. ONE of the following:
   1. The patient has a diagnosis of invasive aspergillosis
      OR
   2. The patient has a diagnosis of invasive mucormycosis
      OR
   3. The patient has another indication that is supported in CMS approved compendia for the requested medication
      AND
2. The patient does NOT have any FDA labeled contraindications to the requested medication

Length of Approval: 6 months

Renewal Evaluation

Cresemba will be approved when ALL of the following are met:

1. The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria
   AND
2. ONE of the following:
   1. The patient has a diagnosis of invasive aspergillosis and patient has continued indicators of active disease (e.g., continued radiologic findings, direct microscopy findings, histopathology findings, positive cultures, positive serum galactomannan assay)
      OR
   2. The patient has a diagnosis of invasive mucormycosis and patient has continued indicators of active disease (e.g., continued radiologic findings, direct microscopy findings, histopathology findings, positive cultures, positive serum galactomannan assay)
      OR
   3. BOTH of the following:
      1. The patient has another indication that is supported in CMS approved compendia for the requested medication
         AND
      2. The patient has had clinical benefit with the requested medication
         AND
3. The patient does NOT have any FDA labeled contraindications to the requested medication

Length of approval: 6 months