Limited Coverage Drugs - Tobramycin (TOBI® and TOBI® Podhaler®)

Generic Name / Strength / Form

tobramycin solution for inhalation / 300 mg; 5 mL – TOBI®
tobramycin inhalation powder / 28 mg / capsule, for use with Podhaler only – TOBI® Podhaler®

Special Authority Criteria

Approval Period

For the cyclic treatment of chronic pulmonary Pseudomonas aeruginosa infections in patients:

With moderate to severe cystic fibrosis

AND

Who do not tolerate injectable forms of tobramycin to manage inhalation issues.

Indefinite

Practitioner Exemptions

  • None

Special Notes

  • Cyclic treatment is measured in 28-day cycles and is defined as 28 days "on" tobramycin followed by 28 days "off."
  • Tobramycin may be prescribed either as monotherapy or as a combination treatment with another therapy chosen by the prescribing physician.
  • Tobramycin is a PharmaCare high-cost drug. PharmaCare reimburses high-cost drugs eligible for coverage to a maximum price based on the manufacturer list price plus a 5 percent mark-up.

Special Authority Request Form(s)