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.  

• amoxicillin 500mg tablets
• amoxicillin/clavulanate potassium extended-release tablet (Augmentin XR®)
• amoxicillin extended release 775mg tablet (Moxatag®)
• cephalexin 500mg tablets
• cephalexin 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 Prior Authorization Criteria

PA criteria:

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

• Prior Authorization form  

PA Criteria

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).
  

 Prior Authorization form  

PA Criteria

1. FDA approved indication of systemic fungal infections with one of the following:

        a. blastomycosis
        b. coccidioidomycosis
        c. histoplasmosis
        d. chromomycosis
        e. 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  

PA Criteria

Sivextro™ (Tedizolid Phosphate) Tablet 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 per six days will apply.
  

Dalvance™ (Dalbavancin) 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 vancomycin, Zyvox® (linezolid), or other cost effective therapeutic equivalent medication(s).
• A quantity limit of two vials per seven days will apply.

Orbactiv™ (Oritavancin) 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 vancomycin, Zyvox® (linezolid), or other cost effective therapeutic equivalent medication(s).
• A quantity limit of three vials per 30 days will apply.
   

 Prior Authorization form