Cephalosporins and Related Antibiotics Prior Authorization Summary
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Summarizes prior authorization (PA) requirements for specified amoxicillin/clavulanate and cephalosporin products for Georgia Medicaid Fee-for-Service; affects prescribers and pharmacists requesting non-preferred formulations or specific strengths. Includes guidance on exceptions, PDL access, PA process, and quantity limits.
No material clinical or coverage changes in this revision.
Coverage criteria for amoxicillin/clavulanate and cephalosporins
Amoxicillin/Clavulanate non-preferred products
Covered when ALL of the following are met for specified amoxicillin/clavulanate products
Applies to: amoxicillin/clavulanate 250-125 mg IR tablets, chewable tablets, and listed suspensions
Various non-preferred cephalosporin products
Covered when ALL of the following are met for listed cephalosporin non-preferred products
Applies to: amoxicillin/clavulanate ER tablets; cefadroxil tablets; cephalexin 750 mg capsules; cephalexin tablets; cefaclor ER tablets (as listed)
Cefixime suspension and cefpodoxime
Covered when ONE of the following is met for cefixime suspension and cefpodoxime
Exceptions to the stated coverage conditions are considered through the prior authorization process. Providers should initiate a PA when seeking an exception and supply supporting documentation to justify coverage of a non-preferred product.
Prior authorization, documentation, and denial triggers
Prior authorization required; submit written request
Prior authorization is required for the listed non-preferred amoxicillin/clavulanate and cephalosporin products. The prescriber must submit a written letter of medical necessity when requesting these non-preferred strengths or products; the PA process may be initiated by calling OptumRx at 1-866-525-5827.
- Applies to specified amoxicillin/clavulanate IR, chewable, suspension, ER products and listed cephalosporin products.
Step/sequence requirement for cefixime and cefpodoxime
For cefixime suspension and cefpodoxime, approval is contingent on ONE of the following: the member was started and stabilized on the agent while in the hospital, OR the organism is resistant/not susceptible to cefdinir or the member has contraindications, drug–drug interactions, or intolerable side effects to cefdinir.
- If not inpatient-started/stabilized, must document cefdinir failure, resistance, contraindication, interaction, or intolerance.
Required: written letter of medical necessity
Prescribers must submit a written letter of medical necessity explaining why the preferred strengths or preferred products are not appropriate for the member when requesting the listed non-preferred amoxicillin/clavulanate and cephalosporin products.
- Letter requirement applies to the specific products listed (see individual product entries for applicable formulations/strengths).
Documentation required for cefixime and cefpodoxime
For cefixime suspension and cefpodoxime, the request must include documentation that the member was started and stabilized on the agent while in the hospital OR documentation that the organism is resistant/not susceptible to cefdinir or the member has contraindications, drug–drug interactions, or intolerable side effects to cefdinir.
- One of these documentation pathways must be provided to meet coverage criteria for these agents.
Denial triggers for missing documentation
Requests that do not include a written letter of medical necessity for non-preferred strengths/products, or that lack the required inpatient-start/stabilization or cefdinir failure/contraindication/intolerance documentation for cefixime or cefpodoxime, will be subject to denial.
- Non-preferred amoxicillin/clavulanate and cephalosporin requests require the medical necessity letter.
- Cefixime and cefpodoxime require inpatient initiation/stabilization documentation or evidence of cefdinir resistance/contraindication/intolerance.
Step therapy requirements for specific agents
| Step | Requirement | Supporting documentation | Coverage status |
|---|---|---|---|
| 1 | |||
| Member was started and stabilized on cefixime suspension or cefpodoxime while in the hospital | |||
| Documentation that the member was started and stabilized on the agent during an inpatient hospital stay | |||
| Covered when met |
Definitions and abbreviations
Policy background and scope
This prior authorization summary addresses oral amoxicillin/clavulanate formulations and first- through third-generation oral cephalosporins. Its purpose is to manage use of non-preferred strengths and formulations by requiring documentation that a preferred product is inappropriate or that clinical circumstances justify an alternative agent.
Quantity limit references
How to request prior authorization and PDL access
To begin prior authorization, providers may call OptumRx at 1-866-525-5827. The Preferred Drug List (PDL) is available online for reference to identify preferred alternatives when preparing documentation for the PA request.
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