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.
No material clinical/coverage changes
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.
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