CurrentAvMedPolicy N/A

Blujepa (gepotidacin) prior authorization / step-edit form

Pharmacy prior authorization and step-edit criteria for Blujepa (gepotidacin) covering uncomplicated urinary tract infection (uUTI) and uncomplicated urogenital gonorrhea in specified age/weight groups, required documentation, trial/failure of listed antibiotics, laboratory confirmation, dosing, and quantity limit.

Policy Summary

PayerAvMed

PolicyBlujepa (gepotidacin) prior authorization / step-edit form

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 all required member, prescriber, drug, and clinical information to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

2Covered Indications

20/tabQuantity limit

>=12Minimum age

Coverage Summary

Pharmacy prior authorization and step-edit criteria for Blujepa (gepotidacin) covering uncomplicated urinary tract infection (uUTI) and uncomplicated urogenital gonorrhea in specified age/weight groups. Required documentation includes lab/culture confirmation of susceptibility or positive test and chart notes documenting trial and failure of listed comparator antibiotics (or documentation of intolerance/drug resistance). Recommended dosing: uUTI — 1500 mg (two 750 mg tablets) orally twice daily for 5 days; Gonorrhea — 3000 mg (four 750 mg tablets) orally, followed by a second 3000 mg dose ~12 hours later. A quantity limit of 20 tablets per 30 days applies.