Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
The use of Tobramycin, inhaled product, may be considered medically necessary for the management of CF when ALL of the following criteria are met:
- The individual is six years of age or older; and
- The individual tests positive for Pseudomonas aeruginosa; and
- The individual is not colonized with Burkholderia cepacia.
The use of Tobramycin, inhaled product, for any other indication is considered experimental/investigational and therefore, non-covered. There is a lack of clinical data to support its effectiveness and safety in other conditions.
Procedure Codes