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 the following criteria is met:
- The individual tests positive for Pseudomonas aeruginosa, either for acute eradication protocol or for chronic inhalation therapy for chronic pseudomonas colonization.
Tobramycin nebs are clinically used for symptomatic pseudomonas tracheitis in children who are tracheostomy dependent.
The use of Tobramycin, inhaled product, not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Codes
