Subject: Oravig Limit Policy 2946-H 10-2021
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ORAVIG
(miconazole buccal tablet)
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Policy:
FDA-approved Indications
Oravig is indicated for the local treatment of oropharyngeal candidiasis (OPC) in adults.
- Precertification Criteria
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LIMIT CRITERIA
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Drug
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1 Month Limit*
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3 Month Limit*
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Oravig
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14 tablets / 25 days
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Does Not Apply**
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* The duration of 25 days is used for a 30-day fill period to allow time for refill processing.
** This drug is for short-term acute use; therefore, the mail limit will be the same as the retail limit. The intent is for prescriptions of the requested drug to be filled one month at a time, even if filled at mail order; there should be no 3 month supplies filled.
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Place of Service:
Outpatient
The above policy is based on the following references:
- Oravig [package insert]. Raleigh, NC: Fortovia Therapeutics Inc.; January 2020.
- Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2021; Accessed August 16, 2021.
- Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed August 16, 2021.
- Pappas PG, Kauffman CA, Andes DA, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Available at https://academic.oup.com/cid/article/62/4/e1/2462830. Accessed August 2021.
- Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Available at https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/Adult_OI.pdf. Accessed August 2021.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
February 26, 2022
