CurrentAvMedPolicy N/A

Pivya (pivmecillinam) prior authorization

Pharmacy prior authorization form and clinical criteria for coverage of Pivya (pivmecillinam) for treatment of uncomplicated urinary tract infections in members; defines patient eligibility, required documentation, step therapy requirements, dosing, quantity limit, and authorization length.

Policy Summary

PayerAvMed

PolicyPivya (pivmecillinam) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescribing physician must sign and print name on the prior authorization form and fax the completed form with required documentation to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

6Required prior antibiotics (must fail all)

9Quantity limit (per 30 days)

18+Minimum age

Coverage Summary

Pivya (pivmecillinam) is covered with clinical criteria for the treatment of uncomplicated urinary tract infections (uUTI) in adults. Approval requires completion of the pharmacy prior authorization form with the prescriber's signature and submission of required documentation (including lab results and chart notes). The form defines dosing as one tablet three times daily for 3 to 7 days as clinically indicated, a quantity limit of 9 tablets per 30 days, and an authorization length equal to the Date of Service.

Initial Therapy Criteria

Initial Authorization / Clinical Criteria

All criteria must be met for approval. To support each line checked, documentation including lab results, diagnostics, and/or chart notes must be provided.

ALL of the following

Member is 18 years of age or older
Member has a diagnosis uncomplicated urinary tract infections (uUTI) caused by susceptible isolates of Escherichia coli, Proteus mirabilis and Staphylococcus saprophyticus
Lab cultures must show that bacteria is sensitive to Pivya (submit documentation)
Trial and failure of ALL the following oral antibiotics unless intolerant or bacteria is drug resistant (submit documentation)
- sulfamethoxazole-trimethoprim
- nitrofurantoin
- ciprofloxacin or levofloxacin
- amoxicillin-clavulanate
- cephalexin
- cefdinir

Definitions & Unproven Uses

Uncomplicated urinary tract infection (uUTI): as used in this form, infection caused by susceptible isolates of Escherichia coli, Proteus mirabilis, and Staphylococcus saprophyticus (documentation required). Approval is limited to infections caused by these specified susceptible isolates; uses outside of these organisms or without culture/sensitivity documentation are outside the scope of this prior authorization.

Provider Actions / Prior Authorization

Prior Authorization

Submit prior authorization request

Prescribing physician must sign and clearly print name on the prior authorization request form and fax the completed form to 1-305-671-0200. Incomplete, incorrect, or illegible information may delay the authorization process.

Documentation Required

Provide culture and sensitivity documentation

Submit lab culture results showing the infecting bacteria are sensitive to Pivya; failure to submit sensitivity documentation may result in denial.

Documentation Required

Document trial and failure of listed antibiotics

Provide chart notes or other documentation confirming trial and failure (or documented intolerance or bacterial resistance) of ALL the following oral antibiotics: sulfamethoxazole-trimethoprim, nitrofurantoin, ciprofloxacin or levofloxacin, amoxicillin-clavulanate, cephalexin, and cefdinir. Previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Denial Risk

Sample use not acceptable for meeting step edit

Use of sample medications to initiate therapy does not satisfy the step edit/preauthorization requirement and will not be accepted as evidence of prior therapy.

Documentation Required

Age confirmation

Confirm and document that the member is 18 years of age or older on the request form; missing age information may delay authorization.

Billing Rule

Length of authorization equals date of service

The length of authorization is specified on the form as the Date of Service.

Background

Pivya is requested for treatment of uncomplicated urinary tract infections caused by specific susceptible organisms. Approval requires submission of culture and sensitivity results showing the bacteria are sensitive to Pivya and documentation of step therapy failure — specifically chart notes or claims demonstrating trial and failure (or intolerance or documented bacterial resistance) of all listed oral antibiotics. The prior authorization form also specifies the recommended dosing, a quantity limit of 9 tablets per 30 days, and that the length of authorization equals the date of service.

Policy Summary

PayerAvMed

PolicyPivya (pivmecillinam) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescribing physician must sign and print name on the prior authorization form and fax the completed form with required documentation to 1-305-671-0200.

SourceLink

On This Page

OpenPayer

Pivya (pivmecillinam) prior authorization

Coverage Summary

Initial Therapy Criteria

Definitions & Unproven Uses

Provider Actions / Prior Authorization

Applicable Codes

Background

Revision History