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
doxycycline monohydrate Approval Criteria:
- Member must have a patient specific, clinically significant reason why the hyclate formulation cannot be used.
acyclovir buccal Tablets (Sitavig®) Approval Criteria:
- 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.
ceftazidime/avibactam (Avycaz™) Approval Criteria:
- 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.
ceftolozane/tazobactam(Zerbaxa™) Approval Criteria:
- 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.
itraconazole oral tablets (Onmel®) Approval Criteria:
- 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.
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