Aztreonam inhalation (Cayston) prior authorization
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This document defines CareOregon's prior authorization criteria for inhaled aztreonam (Cayston) for members, including initial and reauthorization requirements and required clinical documentation.
No material clinical or coverage changes in this revision.
Coverage Criteria for Aztreonam Inhalation (Cayston)
Initial Authorization
Covered when ALL of the following are met:
Approval length 12 months
Reauthorization
Reauthorization covered when ALL of the following are met:
Approval length 12 months
Provider Actions, Documentation & Step Therapy
Prior authorization required (Cayston)
Prior authorization is required for Cayston (aztreonam inhalation). Initial authorizations and reauthorizations are processed with an approval length of 12 months when criteria are met.
Step therapy: prior tobramycin requirement
Request must show prior failure or documented resistance to inhaled tobramycin (TOBI) before approval.
Required clinical documentation
Submit medical records or chart notes confirming Pseudomonas aeruginosa infection and documentation that the member has failed or has documented resistance to tobramycin (TOBI). For reauthorization, submit records demonstrating compliance and clinical response (e.g., increased FEV1 or improved respiratory symptoms).
Denial risk: missing infection or prior antibiotic evidence
Requests missing documentation of Pseudomonas aeruginosa infection, or without evidence of prior failure or documented resistance to tobramycin (TOBI), or with FEV1 outside 25%–90% predicted may be denied.
- Must include chart notes confirming Pseudomonas aeruginosa infection.
- Must include documentation of failure or resistance to inhaled tobramycin (TOBI).
- Member FEV1 must be between 25% and 90% predicted.
Key Clinical Eligibility Metrics
Definitions and Authorization Length
Background
Aztreonam inhalation (Cayston) is an inhaled antibiotic indicated for treatment of Pseudomonas aeruginosa airway infections in patients with chronic respiratory disease. Eligibility under this policy is contingent on documented microbiology and lung function, and approval is granted for a limited period.
Under CareOregon's prior authorization requirement, approvals are issued for 12 months when criteria are met. Initial authorization requires documentation of Pseudomonas aeruginosa infection, a member FEV1 between 25% and 90% predicted, and submission of medical records showing failure of or documented resistance to inhaled tobramycin (TOBI). Reauthorization requires evidence of adherence to therapy and a clinical response, such as increased FEV1 from baseline or improved respiratory symptoms.
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