Aztreonam prior authorization for Georgia Medicaid FFS
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Defines prior authorization (PA) requirements, coverage settings, and administrative guidance for aztreonam injection (preferred generic and non-preferred brand) under Georgia Medicaid Fee-for-Service. Affects providers prescribing/administrating aztreonam and billing for members in Georgia Medicaid FFS.
No material clinical or coverage changes in this revision.
Coverage Criteria
PA Coverage Criteria
Covered when ALL of the following are met
As specified in PA criteria
When aztreonam is administered in a physician's office, billing must follow the DCH physician's injectable program procedures and must not be submitted through the outpatient pharmacy program. Guidance and enrollment information for the physician injectable program are available at www.mmis.georgia.gov.
Initial Authorization Criteria
Initial Authorization
Initial authorization details
Provider Actions & Prior Authorization
Prior authorization required for aztreonam
Aztreonam requires prior authorization. Approvals are granted only for administration in the member's home by home health service or in a long-term care facility; exceptions may be requested through the prior authorization process.
Step therapy not specified
No step therapy requirements are specified in this policy summary.
Initiate PA via OptumRx; billing resources
Initiate prior authorization through OptumRx (1-866-525-5827). For physician office administration billing guidance, see the DCH physician's injectable program information at www.mmis.georgia.gov.
- Call OptumRx to start PA: 1-866-525-5827
- Physician injectable program details: www.mmis.georgia.gov
Approvals limited to home or long-term care
Prior authorization is approvable only when aztreonam is administered in the member's home by home health service or in a long-term care facility; administration in other settings does not meet the PA criteria.
Physician office billing requirement
If aztreonam is administered in a physician's office, it must be billed through the DCH physician's injectable program rather than the outpatient pharmacy program to avoid inappropriate billing.
- Use the DCH physician's injectable program for office-administered drugs
- Billing instructions available at www.mmis.georgia.gov
Permitted Sites of Care
Site-of-care: home or long-term care; office billing note
Approvals are limited to administration in the member's home by home health service or in a long-term care facility. If administered in a physician's office, follow the DCH physician's injectable program billing instructions.
Coding & Billing Notes
| No codes listed |
Step Therapy
| Step | Requirement |
|---|---|
| 1 | |
| No step therapy requirements are specified in this summary. |
Quantity Limits
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