CurrentAvMedPolicy Pub. 100-2

Prior authorization for oritavancin (Kimyrsa, Orbactiv)

Form and criteria governing prior authorization and step-edit requests for outpatient oritavancin (Kimyrsa, Orbactiv) administration for AvMed members; applies to providers requesting coverage for these medical-administered antibiotics.

Policy Summary

PayerAvMed

PolicyPrior authorization for oritavancin (Kimyrsa, Orbactiv)

Policy CodePolicy Pub. 100-2

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete the prior authorization form and submit signed form, recent lab cultures (within 7 days) showing organism sensitivity or resistance, and chart notes documenting trials/failures of required antibiotics.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2brand products listed

7 daysrequired recency for cultures

all listedoral antibiotic trial requirement

48 hrsinpatient continuation timeframe

Coverage Criteria for Oritavancin (Kimyrsa, Orbactiv)

Policy Summary

PayerAvMed

PolicyPrior authorization for oritavancin (Kimyrsa, Orbactiv)

Policy CodePolicy Pub. 100-2

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Primary requirements: Prescribing physician signature on form; diagnosis of acute bacterial skin and skin structure infection (ABSSSI); provider has submitted lab cultures from the current hospital admission or office visit collected within the last 7 days; lab cultures must show that the bacteria is sensitive to the requested antibiotic (Kimyrsa or Orbactiv) or vancomycin; submit all supporting documentation including chart notes and lab results.

From form clinical criteria

Antibiotic trial or resistance (oral): Member must meet ONE of: provider submits chart notes documenting trial and failure of ALL the following oral antibiotics: penicillin VK, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, clindamycin, doxycycline, trimethoprim-sulfamethoxazole, and linezolid; OR cultures (from current inpatient admission or most recent office visit collected within the last 7 days) show resistance to ALL of these oral antibiotics.collected within the last 7 days

Oral antibiotic list and culture recency from form

Antibiotic trial or resistance (IV): Member must meet ONE of: provider submits chart notes documenting trial and failure of ALL the following IV antibiotics: penicillin G, nafcillin, ampicillin, ampicillin-sulbactam, cefazolin, ceftriaxone, vancomycin, daptomycin, clindamycin, and linezolid; OR cultures (from current inpatient admission or most recent office visit collected within the last 7 days) show resistance to ALL of these IV antibiotics.collected within the last 7 days

IV antibiotic list and culture recency from form

Continuation therapy

Continuation of therapy after inpatient administration covered when ALL of the following are met

Continuation requirements: Prescribed by an infectious disease specialist; requested medication is for administration only in the specified health system infusion center (not for use in the hospital or emergency department); patient discharged from a qualified hospital; medication must be administered in the specified infusion center within 48 hours of discharge; use is limited to designated situations (drug abuse patients or when physician does not want patient to have a PICC line).within 48 hours of discharge

Continuation-specific fields on form

Requests for oritavancin intended for administration in a hospital or emergency department are not eligible for the outpatient continuation pathway. Continuation coverage is limited to outpatient infusion center use (e.g., specified health system infusion center) for patients discharged from a qualified hospital and prescribed by an infectious disease specialist; the medication must be administered in the infusion center within 48 hours of discharge and is not for in-hospital or ED use.

Coding and Clinical Data Requirements

Covered HCPCS CodesHCPCSCovered

J2406	Kimyrsa (oritavancin)
J2407	Orbactiv (oritavancin)

Culture recency — collected within the last 7 days

Required window for culturesLab cultures must be from the current hospital admission or office visit collected within the last 7 days.

Purpose of culturesCultures must demonstrate organism sensitivity to the requested antibiotic (Kimyrsa or Orbactiv) or to vancomycin.

Acceptable sourceCultures may be retrieved from the most recent office visit or current inpatient admission.

Infusion timing post-discharge — within 48 hours of discharge

Administration timeframe post-dischargeRequested medication must be administered in the infusion center within 48 hours of discharge.

Prescriber requirementContinuation must be prescribed by an infectious disease specialist.

Site restrictionMedication is for infusion center use (Sentara/other health system infusion center) and not for use in the hospital or emergency department.

Discharge sourcePatient must be discharged from a Sentara hospital or other qualified hospital for this continuation pathway to apply.

Provider Actions, Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Kimyrsa (J2406) or Orbactiv (J2407). The prescriber must complete and sign the PA form; incomplete, incorrect, or illegible submissions may delay or result in denial of authorization.

Affected HCPCS: J2406 (Kimyrsa), J2407 (Orbactiv)
Fax completed form to 1-877-535-1391
Prescribing physician signature and printed name required (preprinted stamps not valid)

Step Therapy

Step therapy / Antibiotic Trials

Approval requires documented trial and failure of — or culture-proven resistance to — a comprehensive list of oral antibiotics OR a comprehensive list of IV antibiotics. Provider must submit supporting chart notes or culture results collected within the past 7 days.

Oral antibiotics that must be tried and failed or shown resistant by culture: penicillin VK, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, clindamycin, doxycycline, trimethoprim-sulfamethoxazole, linezolid
IV antibiotics that must be tried and failed or shown resistant by culture: penicillin G, nafcillin, ampicillin, ampicillin-sulbactam, cefazolin, ceftriaxone, vancomycin, daptomycin, clindamycin, linezolid
Cultures must be from the current hospital admission or office visit and collected within the last 7 days

Documentation Required

Required Submission Documents

Prescribing physician must sign and clearly print their name on the request form (preprinted stamps are not valid). Submit lab cultures from the current admission or office visit collected within the last 7 days and chart notes documenting trials/failures where applicable. All documentation (labs, diagnostics, chart notes) must be provided or the request may be denied.

Required: prescriber signature and printed name on PA form
Required: lab cultures showing organism sensitivity to requested antibiotic (Kimyrsa or Orbactiv) or vancomycin
Required: culture collection date within 7 days of request
Required: chart notes documenting trial and failure of listed oral or IV antibiotics when applicable

Denial Risk

Incomplete or Illegible Submission

Authorization can be delayed or denied if the form information is incomplete, incorrect, or illegible, or if required supporting documentation (labs, diagnostics, chart notes) is missing.

Ensure phone and fax numbers on form are correct to avoid unnecessary delays
Incomplete or illegible information on the form may delay or result in denial

Definitions

ABSSSI — Acute bacterial skin and skin structure infection

Eligible diagnosisAcute bacterial skin and skin structure infection (ABSSSI) as listed on the form.

Documentation requiredProvider must submit lab cultures from current admission or office visit collected within the last 7 days.

Culture interpretationLabs must show bacterial sensitivity to the requested antibiotic or to vancomycin.

Antibiotic trial/resistance criteriaMember must meet one of: documented trial and failure of all listed oral antibiotics OR cultures showing resistance to all listed oral antibiotics (penicillin VK; amoxicillin; amoxicillin-clavulanate; dicloxacillin; cephalexin; clindamycin; doxycycline; trimethoprim-sulfamethoxazole; linezolid).

OpenPayer

Prior authorization for oritavancin (Kimyrsa, Orbactiv)

Coverage Criteria for Oritavancin (Kimyrsa, Orbactiv)

Coding and Clinical Data Requirements

Provider Actions, Authorization & Documentation

Background

Definitions