CurrentAvMedPolicy N/A

Sivextro (tedizolid phosphate) — Prior Authorization and Step-Edit Criteria (Medical, J3090)

Prior authorization and step-edit criteria for medical (J3090) use of Sivextro (tedizolid phosphate) for ABSSSI administered in medical settings; affects AvMed members and prescribing providers requesting outpatient/medical benefit coverage.

Policy Summary

PayerAvMed

PolicySivextro (tedizolid phosphate) — Prior Authorization and Step-Edit Criteria (Medical, J3090)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit complete prior authorization with prescriber signature, required member/prescriber info, dosing and duration, diagnosis/ICD, culture results (collected within 7 days), and chart notes documenting antibiotic trials or resistance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Length of auth (days)

J3090HCPCS

7Culture max age (days)

72Inpatient threshold (hrs)

Coverage Criteria for Sivextro (tedizolid phosphate)

Policy Summary

PayerAvMed

PolicySivextro (tedizolid phosphate) — Prior Authorization and Step-Edit Criteria (Medical, J3090)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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.

Initial approval - required items: Provider submits complete PA form with prescriber signature and required member/prescriber information; drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight if applicable, and supporting documentation (labs, cultures, chart notes).

See documentation module for specifics

Diagnosis: Member has a diagnosis of acute bacterial skin and skin structure infection (ABSSSI).

Culture and sensitivity: Provider has submitted lab cultures from current hospital admission or office visit collected within the last 7 days showing bacteria sensitive to Sivextro or linezolid; cultures must be provided or request may be denied.collected within last 7 days

Antibiotic trial or documented resistance - oral: Member must meet ONE of: (1) chart notes documenting trial and failure of ALL listed oral antibiotics (penicillin VK, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, clindamycin, doxycycline, trimethoprim-sulfamethoxazole, and linezolid) OR (2) cultures show resistance to ALL these oral antibiotics.

Provider must submit chart notes or culture results

Antibiotic trial or documented resistance - IV: Member must meet ONE of: (1) chart notes documenting trial and failure of ALL listed IV antibiotics (penicillin G, nafcillin, ampicillin, ampicillin-sulbactam, cefazolin, ceftriaxone, vancomycin, daptomycin, clindamycin, and linezolid) OR (2) cultures show resistance to ALL these IV antibiotics.

Provider must submit chart notes or culture results

Continuation Therapy

Covered when ALL of the following are met

Continuation - inpatient exposure: Member is currently on Sivextro for more than 72 hours inpatient; progress notes must be submitted.> 72 hours

Continuation - culture sensitivity: Provider has submitted lab culture sensitivity results retrieved during inpatient admission which show resistance to ALL preferred antibiotics except for Sivextro (Sivextro sensitive).

Coding and Clinical Test Requirements

Covered HCPCS CodeHCPCSCovered

J3090

Injection, tedizolid phosphate, per 1 mg (Medical)

Culture recency — collected within the last 7 days

ThresholdCollected within the last 7 days

Applies toLab cultures from current hospital admission or office visit

PurposeDemonstrate bacteria sensitive to Sivextro or linezolid or show resistance to listed antibiotics

Inpatient exposure for continuation — > 72 hours

Threshold> 72 hours

ContextMember is currently on Sivextro inpatient for more than 72 hours

Required documentationProgress notes must be submitted to support continuation

Provider Submission, Prior Authorization, and Step Therapy

Prior Authorization

Prior authorization required for Sivextro (J3090)

Prior authorization is required when Sivextro is billed under HCPCS code J3090 (medical benefit). All clinical criteria and supporting documentation listed on the PA form must be provided for approval; incomplete submissions may delay authorization.

Drug Requested: Sivextro (tedizolid phosphate) (J3090) (Medical)
All clinical criteria must be met for approval; supporting documentation (labs, diagnostics, chart notes) must be provided

Step Therapy

Step therapy and continuation requirements

Document either trials and failures of the listed preferred oral and/or IV antibiotics or submit culture results showing resistance to those agents; continuation after inpatient use requires >72 hours of inpatient administration with progress notes and culture sensitivity showing only Sivextro is susceptible.

Oral: chart notes documenting trial and failure of ALL listed oral antibiotics (penicillin VK, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, clindamycin, doxycycline, trimethoprim-sulfamethoxazole, and linezolid) OR cultures showing resistance to ALL these oral agents
IV: chart notes documenting trial and failure of ALL listed IV antibiotics (penicillin G, nafcillin, ampicillin, ampicillin-sulbactam, cefazolin, ceftriaxone, vancomycin, daptomycin, clindamycin, and linezolid) OR cultures showing resistance to ALL these IV agents
Continuation: member on Sivextro >72 hours inpatient (progress notes) plus inpatient culture sensitivity showing resistance to all preferred antibiotics except Sivextro

Documentation Required

Required submission elements

Ensure the PA form includes prescriber signature and complete member/prescriber information, plus drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code, weight if applicable, lab culture results (collected within the last 7 days), and chart notes documenting trials or resistance as specified.

Prescriber signature (preprinted stamps not valid) and prescriber contact/NPI
Member name, AvMed ID, and DOB
Drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code, weight and date obtained if applicable
Lab cultures collected within the last 7 days and chart notes documenting trials/failures or resistance

Denial Risk

Documentation completeness triggers

Authorization may be delayed or the request denied if the PA form information is incomplete, incorrect, or illegible; failure to provide required clinical documentation (labs, diagnostics, chart notes) will result in denial.

Incomplete/incorrect/illegible form information can delay authorization
Missing lab results, diagnostics, or chart notes supporting criteria can result in denial

Background

Sivextro (tedizolid phosphate) is requested for treatment of acute bacterial skin and skin structure infections (ABSSSI). The policy requires submission of a complete prior authorization form with a prescriber signature and all member/prescriber information, the drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code, and supporting clinical documentation including lab cultures and chart notes.

Approval for initiation requires documentation of culture and sensitivity data obtained within the specified timeframe and evidence of trial and failure of, or documented resistance to, the listed preferred oral and/or IV antibiotics as detailed in the criteria. Continuation of therapy after inpatient administration has specific requirements including inpatient exposure of > 72 hours with progress notes and culture sensitivity results showing susceptibility to Sivextro when other preferred agents are not effective.

For urgent reviews, providers should contact AvMed’s Pre-Authorization Department. Note that use of samples to initiate therapy does not satisfy step edit/prior authorization criteria and previous therapies will be verified through pharmacy claims or submitted chart notes.

OpenPayer

Sivextro (tedizolid phosphate) — Prior Authorization and Step-Edit Criteria (Medical, J3090)

Coverage Criteria for Sivextro (tedizolid phosphate)

Coding and Clinical Test Requirements

Provider Submission, Prior Authorization, and Step Therapy

Background

Definitions