Special formulation 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 250mg and 500mg tablets
- cephalexin 750mg capsule (Keflex® 750mg)
- doxycycline hyclate delayed-release tablet (Doryx®)
- doxycycline monohydrate extended-release 40mg capsule (Oracea®)
- Minocycline ER tablets (Minolira™)
- minocycline extended-release tablet (Solodyn®)
- minocycline extended-release (Ximino™)
- minocycline hcl 50mg, 75mg, 100mg tablets
PA Criteria: doxycycline monohydrate immediate-release 75mg capsules, 150mg capsules, and 150mg tablets Approval Criteria:
- Member must have a patient specific, clinically significant reason why the hyclate formulation cannot be used.
doxycycline hyclate (Acticlate®) 75mg capsules Oral Antibiotic Special Formulation Approval 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.
acyclovir 5% ointment (Zovirax®) Approval Criteria:
- An FDA approved indication of management of initial genital herpes or in limited non-life-threatening mucocutaneous herpes simplex virus (HSV) infections in immunocompromised patients; AND
- A patient-specific, clinically significant reason why the member cannot use oral acyclovir, famciclovir, or valacyclovir tablets.
acyclovir 200mg/5mL suspension (Zovirax®) Approval Criteria:
- An age restriction of seven years and younger will apply. Members older than seven years of age will require a patient-specific, clinically significant reason why a special formulation product is needed.
acyclovir buccal Tablets (Sitavig®), acyclovir/hydrocortisone 5%/1% cream (Xerese®), and penciclovir 1% cream (Denavir®) Approval Criteria:
- An FDA approved diagnosis of recurrent herpes labialis (cold sores); AND
- A patient-specific, clinically significant reason why the member cannot use oral acyclovir, famciclovir or valacyclovir oral tablets; AND
- A patient-specific, clinically significant reason why the member cannot use acyclovir cream.
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
- Hospital-acquired Bacterial Pneumonia and Ventilator-associated Bacterial Pneumonia (HABP/VABP); 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.
minocycline Tablets Approval Criteria:
- Approval requires a patient-specific, clinically significant reason why the member requires the immediate-release tablet formulation and cannot use the immediate-release capsule formulation and/or other cost effective therapeutic equivalent medication(s).
minocycline extended-release (Ximino™) Approval Criteria:
- An FDA approved diagnosis of inflammatory lesions of non-nodular moderate to severe acne vulgaris; AND
- Member must be 12 years of age or older; AND
- Ximino™ is not covered for members older than 20 years of age; AND
- A patient-specific, clinically significant reason why the member cannot use the immediate-release capsule formulation or and/or other cost effective therapeutic equivalent medication(s).
tetracycline 250mg and 500mg Oral Capsules Approval Criteria:
- Approval requires a patient-specific, clinically significant reason why the member requires tetracycline and cannot use doxycycline or minocycline capsules and/or other cost effective therapeutic equivalent medication(s).
Prior Authorization form |