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Special Formulation

Antibiotic Special formulation Prior Authorization Criteria

Consideration will be based on ALL of the following criteria:

  • PA criteria
    • Member must have a patient specific, clinically significant reason why the immediate release formulation and/or other cost effective therapeutic equivalent medication(s) cannot be used.
      1. amoxicillin/clavulanate potassium extended-release tablet (Augmentin XR®)
      2. doxycycline hyclate delayed-release tablet (Doryx®)
      3. cephalexin 750mg capsule (Keflex® 750mg)
      4. amoxicillin extended release 775mg tablet (Moxatag®)
      5. doxycycline monohydrate extended-release 40mg capsule (Oracea®)
      6. minocycline extended-release tablet (Solodyn®)
Doxycycline Monohydrate Prior Authorization Criteria

  • PA criteria
    • Member must have a patient specific, clinically significant reason why the hyclate formulation cannot be used.
    • Prior Authorization Form
Ketoconazole Oral Tablets
  • PA Criteria
    1. FDA approved indication of systemic fungal infections with one of the following:
      1. blastomycosis
      2. coccidioidomycosis
      3. histoplasmosis
      4. chromomycosis
      5. paracoccidioidomycosis; and
    2. Member is 3 years old or older; and
    3. Member does not have underlying hepatic disease; and
    4. Trials with other effective oral antifungal therapies, including fluconazole, itraconazole, and voriconazole, have failed to resolve infection; or
    5. Other effective oral antifungal therapies are not tolerated or potential benefits outweigh the potential risks; and
    6. Hepatic function tests must be done at baseline and weekly during treatment.
    7. A clinical exception may apply for members with a diagnosis of Cushing’s disease when other modalities are not available.

Last Modified on Jun 16, 2021
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