Daptomycin (Cubicin, Cubicin RF) (PDF)
Clinical policy defining medical necessity criteria, dosing limits, prior authorization requirements, indications covered and not covered, and coding implications for daptomycin (including Cubicin RF) across Commercial, HIM, and Medicaid lines of business.
3Q 2025 annual review: removed references to Cubicin and Dapzura RT as these branded products are discontinued; added 350 mg strength to Section VI; added step therapy bypass for IL HIM per IL HB 5395.
3Q 2024 annual review: no significant changes; references reviewed and updated.
3Q 2023 annual review: added HCPCS code J0877; references reviewed and updated.
3Q 2022 annual review: added requirement for use of generic daptomycin if request is for brand Cubicin/Cubicin RF; removed left-sided endocarditis from Section III and added requirements to allow use after failure of vancomycin per AHA 2015 Infective Endocarditis Scientific Statement.