Antibiotics

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®)

• PA criteria
  • Member must have a patient specific, clinically significant reason why the hyclate formulation cannot be used.
  • Prior Authorization Form
    

• 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.
     
     
  • Prior Authorization Form