CurrentAvMedPolicy N/A

Xerava (eravacycline) IV prior authorization

Defines prior authorization and step-edit requirements for outpatient/inpatient use of Xerava (eravacycline) for AvMed members, including documentation and clinical criteria for new starts and continuation after inpatient administration.

Policy Summary

PayerAvMed

PolicyXerava (eravacycline) IV prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization is required for Xerava (J0122) with documentation of clinical criteria for new starts or continuation after inpatient use.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 dayslength of authorization

18+min age (years)

72inpatient threshold (hrs)

7culture recency (days)

Coverage Criteria for Xerava (eravacycline)

Initial Therapy

Covered when ALL of the following are met

Initial Therapy for cIAI: Member is 18 years of age or older; Member has a diagnosis of complicated intra-abdominal infection (cIAI) with limited or no alternative treatment options; Provider has submitted lab cultures from current hospital admission or office visit collected within the last 7 days; Lab cultures must show that bacteria is sensitive to Xerava; Member must meet ONE of the following:

Prior therapy or resistance: Provider must submit chart notes documenting trial and failure of ALL the following IV antibiotics: ciprofloxacin, levofloxacin, ceftriaxone, cefazolin, cefepime, piperacillin-tazobactam, trimethoprim-sulfamethoxazole, ertapenem, imipenem-cilastatin, and meropenem OR Cultures (retrieved from most recent office visit or current inpatient admission collected within the last 7 days) show resistance to ALL the following IV antibiotics: ciprofloxacin, levofloxacin, ceftriaxone, cefazolin, cefepime, piperacillin-tazobactam, trimethoprim-sulfamethoxazole, ertapenem, imipenem-cilastatin, and meropenem

Provider must supply supporting documentation for the pathway selected (chart notes or culture sensitivity results)

Continuation Therapy

Policy Summary

PayerAvMed

PolicyXerava (eravacycline) IV prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization is required for Xerava (J0122) with documentation of clinical criteria for new starts or continuation after inpatient use.

SourceLink

On This Page

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Coding and Clinical Evidence Requirements

Drug HCPCS CodeHCPCSCovered

J0122

Xerava (eravacycline) IV

inv-05: Culture recency

Culture collection windowRequired lab cultures must be collected within the last 7 days (from current hospital admission or office visit)

Supported specimen sourceCultures may be from the current hospital admission or most recent office visit

PurposeCultures must demonstrate bacterial susceptibility or resistance to inform new start or step-therapy decisions

inv-06: Inpatient duration for continuation

Inpatient duration thresholdMember must have been on Xerava for more than 72 hours inpatient to qualify for outpatient continuation

Required documentationProgress notes from the inpatient stay must be submitted to support the >72-hour inpatient administration

ContextApplies to continuation of therapy following inpatient administration

Provider Submission Requirements and Authorization Rules

Prior Authorization

Prior authorization required for Xerava (J0122)

Prior authorization is required for Xerava (eravacycline) IV (HCPCS J0122). Requests must include documentation of the applicable clinical criteria for a new outpatient start or for continuation after inpatient use.

Drug requested: Xerava (eravacycline) IV (J0122).
Authorization requires documentation supporting checked clinical criteria for New Start or Continuation.

Step Therapy

Document trial/failure of preferred IV antibiotics or culture-proven resistance

Provider must document trial and failure of all listed preferred IV antibiotics OR submit cultures showing resistance to all listed agents; for continuation after inpatient use, inpatient culture sensitivity results must show resistance to all preferred antibiotics except Xerava.

Preferred IV antibiotics that must be trialed and failed (or shown resistant on cultures): ciprofloxacin; levofloxacin; ceftriaxone; cefazolin; cefepime; piperacillin‑tazobactam; trimethoprim‑sulfamethoxazole; ertapenem; imipenem‑cilastatin; meropenem.
For continuation, submit inpatient culture sensitivity results demonstrating resistance to all preferred antibiotics except Xerava.

Documentation Required

Required submission elements for prior authorization

The prior authorization request must include a signed prescriber name/signature and complete member/prescriber details, drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code if applicable, weight and date, and relevant lab/culture results and chart notes.

Prescriber signature and printed name (preprinted stamps not valid).
Member name, AvMed number, date of birth, prescriber name, office contact, phone/fax, NPI.
Drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight and date weight obtained.
Submit lab cultures collected within the last 7 days and chart notes or inpatient progress notes when applicable, including culture sensitivity results.

Denial Risk

Incomplete or missing clinical documentation may delay or lead to denial

Authorization can be delayed or denied if the form is incomplete, incorrect, or illegible, or if required supporting documentation (lab results, diagnostics, chart notes, inpatient progress notes) for checked clinical criteria is not provided.

Incomplete, incorrect, or illegible information may delay authorization.
Failure to provide required lab results, diagnostics, or chart notes supporting checked clinical criteria may result in denial.

Definitions and Request Types

inv-12: New Start

What qualifies as a New Start requestAuthorization request for initiating outpatient Xerava (New Start) must be indicated on the form and accompanied by required documentation

Required culturesProvider must submit lab cultures from the current hospital admission or office visit collected within the last 7 days

Susceptibility evidenceSubmitted lab cultures must show that the bacteria are sensitive to Xerava

Prior therapy or resistance documentationProvider must either submit chart notes documenting trial and failure of all listed IV antibiotics OR cultures showing resistance to all listed IV antibiotics

inv-13: Continuation after inpatient administration

Eligibility for outpatient continuationRequest must indicate continuation following inpatient administration when member has been on Xerava >72 hours inpatient

Inpatient culture sensitivity requirementProvider must submit lab culture sensitivity results retrieved during the inpatient admission showing resistance to ALL preferred antibiotics except Xerava (which is sensitive)

Supporting inpatient documentationProgress notes from the inpatient stay must be provided to document inpatient administration and support continuation

OpenPayer

Xerava (eravacycline) IV prior authorization

Coverage Criteria for Xerava (eravacycline)

Coding and Clinical Evidence Requirements

Provider Submission Requirements and Authorization Rules

Definitions and Request Types

Background