Antibiotics

Prior Authorization Criteria

Consideration will be based on ALL of the following 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.
  • amoxicillin 500mg tablets
  • amoxicillin/clavulanate potassium extended-release tablet (Augmentin XR®)
  • amoxicillin extended release 775mg tablet (Moxatag®)
  • cephalexin 500mg tabletscephalexin 750mg capsule (Keflex® 750mg)
  • doxycycline hyclate delayed-release tablet (Doryx®)
  • doxycycline monohydrate extended-release 40mg capsule (Oracea®)
  • minocycline extended-release tablet (Solodyn®)
  • minocycline hcl 50mg, 75mg, 100mg tablets

• Member must have a patient specific, clinically significant reason why the hyclate formulation cannot be used.

• An FDA approved diagnosis of recurrent herpes labialis (cold sores); AND
• A patient-specific, clinically significant reason why the member cannot use acyclovir or valacyclovir oral tablets.

• An FDA approved diagnosis of one of the following infections caused by designated susceptible microorganisms:
  • Complicated intra-abdominal infections (cIAI), used in combination with metronidazole; OR
  • Complicated urinary tract infections (cUTI), including Pyelonephritis; and
• Member must be 18 years of age or older; AND
• For the diagnosis of cIAI, Avycaz™ must be used in combination with metronidazole; AND
• A patient-specific, clinically significant reason why the member cannot use an appropriate penicillin-beta lactamase inhibitor combination (e.g. piperacillin-tazobactam), a carbapenam (e.g. ertapenem, meropenem, imipenem-cilastatin), a cephalosporin (e.g.  ceftriaxone, ceftazidime) in combination with metronidazole, or other cost effective therapeutic equivalent medication(s).
• A quantity limit of 42 vials per 14 days will apply.

• An FDA approved diagnosis of one of the following infections caused by designated susceptible microorganisms:
  • Complicated intra-abdominal infections (cIAI), used in combination with metronidazole; OR
  • Complicated urinary tract infections (cUTI), including Pyelonephritis; and
• Member must be 18 years of age or older; and
• For the diagnosis of cIAI, Zerbaxa™ must be used in combination with metronidazole; AND
• A patient-specific, clinically significant reason why the member cannot use an appropriate penicillin-beta lactamase inhibitor combination (e.g. piperacillin-tazobactam), a carbapenam (e.g. ertapenem, meropenem, imipenem-cilastatin), a cephalosporin (e.g.  ceftriaxone, ceftazidime) in combination with metronidazole, or other cost effective therapeutic equivalent medication(s).
• A quantity limit of 42 vials per 14 days will apply.

• An FDA approved diagnosis of onychomychosis of the toenail caused by Trichophyton rubrum or T. mentagrophytes; AND
• A patient-specific, clinically significant reason why itraconazole 100mg oral capsules cannot be used in place of Onmel® 200mg tablets.
  

Suprax® (Cefixime), Cedax® (Ceftibuten), and Spectracef® (Cefditoren) Approval Criteria:

• Indicated diagnosis or infection known to be susceptible to requested agent; AND
• A patient-specific, clinically significant reason why the member cannot use cephalexin and cefdinir, or other cost effective therapeutic equivalent medication(s).

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.
   

Sivextro™ (Tedizolid Phosphate) Tablet or Vial Approval Criteria:

• An indicated diagnosis or infection known to be susceptible to requested agent and resistant to the cephalosporin-class of antibiotics and other antibiotics commonly used for diagnosis or infection; AND
• A patient-specific, clinically significant reason why the member cannot use Zyvox® (linezolid), or other cost effective therapeutic equivalent medication(s).
• A quantity limit of six tablets or vials per six days will apply.

• An indicated diagnosis or infection known to be susceptible to requested agent and resistant to the cephalosporin-class of antibiotics and other antibiotics commonly used for diagnosis or infection; AND
• A patient-specific, clinically significant reason why the member cannot use vancomycin, Zyvox® (linezolid), or other cost effective therapeutic equivalent medication(s).
• A quantity limit of two vials per seven days will apply.

• An indicated diagnosis or infection known to be susceptible to requested agent and resistant to the cephalosporin-class of antibiotics and other antibiotics commonly used for diagnosis or infection; AND
• A patient-specific, clinically significant reason why the member cannot use vancomycin, Zyvox® (linezolid), or other cost effective therapeutic equivalent medication(s).
• A quantity limit of three vials per 30 days will apply.