CurrentNeighborhood Health Plan of Rhode IslandPolicy 1880-A

Cayston (aztreonam for inhalation solution) coverage — cystic fibrosis with Pseudomonas aeruginosa

This policy governs coverage and prior authorization criteria for Cayston (aztreonam for inhalation solution) for members of Neighborhood Health Plan of Rhode Island when used for cystic fibrosis with Pseudomonas aeruginosa. It applies to pharmacy benefit claims for the drug.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCayston (aztreonam for inhalation solution) coverage — cystic fibrosis with Pseudomonas aeruginosa

Policy CodePolicy 1880-A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization and document member is ≥2 years old with presence or history of Pseudomonas aeruginosa; authorization may be granted for up to 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization period granted for initial and continuation therapy

>=2 yrsminimum member age for authorization

P. aeruginosarequired presence or history for covered use in CF

FDA-approved onlyother indications not medically necessary

Coverage Criteria for Cayston (aztreonam for inhalation)

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Initial Therapy

Covered when ALL of the following are met

Initial Authorization Criteria: Member is 2 years of age or olderage >= 2 years

Microbiology Requirement: Pseudomonas aeruginosa is present in airway cultures OR member has a history of Pseudomonas aeruginosa infection or colonization in the airways

Indication: Use is for improving respiratory symptoms in cystic fibrosis (FDA‑approved indication)

Other indications are considered experimental/investigational and not medically necessary.

Continuation Therapy

Covered when ALL of the following are met

Reauthorization Criteria: Request is for continued treatment for an indication listed in the coverage criteria

Clinical Benefit: Member is experiencing benefit from therapy as evidenced by disease stability or disease improvement

Authorization may be granted for 12 months.

Requests for uses of Cayston (aztreonam for inhalation solution) outside the FDA-approved indication — that is, other than to improve respiratory symptoms in cystic fibrosis patients with Pseudomonas aeruginosa — are considered experimental/investigational and not medically necessary.

Because the evidence and the FDA approval are specific to the cystic fibrosis population with documented Pseudomonas aeruginosa infection, Cayston will not be authorized for alternative indications, and such requests will be denied as not medically necessary.

Coding and Age Limits

DrugNDC

aztreonam for inhalation solution

Cayston (drug name listed; no numeric codes provided in document)

Minimum age

Minimum age for authorization>= 2 years

Authorization periodMay be granted for up to 12 months

ApplicabilityMembers with cystic fibrosis when Pseudomonas aeruginosa is present or there is a history of infection/colonization

Cayston definition

Brand nameCayston

Generic nameaztreonam for inhalation solution

ScopeIncludes both brand and generic and all dosage forms and strengths unless otherwise stated

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Cayston. Authorizations may be granted for up to 12 months for eligible members.

Authorization period: up to 12 months

Documentation Required

Document in the request that the member is ≥ 2 years of age and that Pseudomonas aeruginosa is present in airway cultures or there is a history of Pseudomonas aeruginosa infection/colonization of the airways.

Member age: ≥ 2 years
Microbiology: Pseudomonas aeruginosa present OR history of Pseudomonas aeruginosa infection/colonization

Note

Provider Action — Source Location

Preserve source location for provider-action content from the Indications section.

Denial Risk

Non–FDA‑Approved Uses

Requests for uses not FDA-approved (or not listed in coverage criteria) will be considered but are typically denied as experimental/investigational.