Limited coverage criteria – tobramycin

Last updated on March 24, 2025

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Generic name	Strength, form & brand name
tobramycin solution (for inhalation)	300 mg; 5 mL - TOBI®
tobramycin inhalation (powder)	28 mg capsule, for use with – TOBI® Podhaler® only

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

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% mark-up

Special Authority request form(s)

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HLTH 5328 – General Special Authority request (PDF, 656KB

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