Currentsierra health and lifePolicy N/A

Vancocin – Prior Authorization/Notification (PDF)

Prior authorization/notification policy for Vancocin (vancomycin) oral capsules for treatment of Clostridium difficile-associated diarrhea (CDAD) and staphylococcal enterocolitis, specifying initial authorization, reauthorization, and clinical rules. Applies to UnitedHealthcare Pharmacy Services - Nevada program effective 01/01/2020 with P&T approvals in 12/2019 and 12/2020.

Policy Summary

Payersierra health and life

PolicyVancocin – Prior Authorization/Notification (PDF)

Policy CodePolicy N/A

Change TypeNotification program created; annual review (no clinical changes)

Effective DateJan 1, 2020

Next Review Date

Key ActionPrior authorization/notification is required for Vancocin (vancomycin) oral capsules per the UnitedHealthcare Pharmacy Services Nevada program; approvals may be issued based on prior claims/medication history, diagnosis codes (ICD-10), and/or claim logic.

SourceLink

POLICY UPDATE CHANGES

Vancocin (vancomycin oral capsules) Notification program created November 2019 and new program November 2020.

10Authorization duration (staphylococcal enterocolitis)

2Indications listed

2019/2020P&T Approval Dates

Coverage Summary

This policy is a prior authorization/notification requirement for Vancocin (vancomycin) oral capsules used to treat Clostridium difficile-associated diarrhea (CDAD) and enterocolitis caused by Staphylococcus aureus. It defines clinical pathways for initial authorization, reauthorization, and staphylococcal enterocolitis, and includes requirements for prescriber justification when the preferred oral solution is not used. The policy applies to the UnitedHealthcare Pharmacy Services - Nevada program, effective 01/01/2020, with P&T approval dates of 12/2019 and 12/2020.

Key facts

Authorization duration (staphylococcal enterocolitis)10 days

Indications listedClostridium difficile-associated diarrhea (CDAD); Staphylococcus aureus enterocolitis

P&T Approval Dates12/2019 & 12/2020

Effective date01/01/2020

Last review12/01/2020 (annual review noted; no changes)

Initial Therapy Criteria

Initial Authorization

Covered when ALL of the following are met:

ALL of the following

Diagnosis of Clostridium difficile-associated diarrhea (CDAD)
ONE of
- History of failure, contraindication, or intolerance to Firvanq (vancomycin) oral solution
- Prescriber provides a reason or special circumstance the patient cannot use Firvanq (vancomycin) oral solution
  Prescriber-documented reason/special circumstance required

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Continuation / Reauthorization Criteria

Reauthorization (CDAD)

Covered when ALL of the following are met:

ALL of the following

Recurrence of Clostridium difficile infection after prior treatment with vancomycin oral capsules

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Staphylococcal Enterocolitis Criteria

Staphylococcal enterocolitis - Initial Authorization

Covered when ALL of the following are met:

ALL of the following

Diagnosis of enterocolitis caused by Staphylococcus aureus
ONE of
- History of failure, contraindication, or intolerance to Firvanq (vancomycin) oral solution
- Prescriber provides a reason or special circumstance the patient cannot use Firvanq
  Prescriber-documented reason/special circumstance required

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Provider Actions & Authorization Rules

Prior Authorization

Prior authorization/notification requirement

Prior authorization/notification is required for Vancocin (vancomycin) oral capsules per the UnitedHealthcare Pharmacy Services Nevada program; approvals may be issued based on prior claims/medication history, diagnosis codes (ICD-10), and/or claim logic.

Documentation Required

Prescriber justification for using capsules vs solution

When the patient has not tried Firvanq oral solution, the prescriber must document a reason or special circumstance that the patient cannot use Firvanq or document a history of failure, contraindication, or intolerance to Firvanq.

Billing Rule

Authorization duration for staphylococcal enterocolitis

Authorization for staphylococcal enterocolitis will be issued for 10 days.

Clinical Evidence & Definitions

Firvanq: the branded vancomycin oral solution referenced in the policy as the first-line / formulary-preferred oral formulation; policy criteria require history of failure, contraindication, or intolerance to Firvanq or a prescriber-documented reason the patient cannot use Firvanq before approving Vancocin capsules.

Primary references: Vancocin [package insert] (ANI Pharmaceuticals, August 2020); Firvanq [package insert] (CutisPharma, January 2018); IDSA/SHEA 2017 Clinical Practice Guidelines for Clostridium difficile Infection (McDonald et al., Clin Infect Dis. 2018); and the UpToDate summary on C. difficile infection (Kelly, accessed November 11, 2020).

Background

Vancocin (vancomycin) oral capsules and Firvanq (vancomycin) oral solution are indicated for treatment of Clostridium difficile-associated diarrhea (CDAD) and enterocolitis caused by Staphylococcus aureus. Parenteral (intravenous) vancomycin is not effective for these gastrointestinal infections; therefore vancomycin must be administered orally for these indications.

Revision History

11/2020reviewLatest

Annual review noted in 11/2020 with no changes to clinical criteria.

11/2019added

Notification program created November 2019 (Vancocin notification change).

Policy Summary

Payersierra health and life

PolicyVancocin – Prior Authorization/Notification (PDF)

Policy CodePolicy N/A

Change TypeNotification program created; annual review (no clinical changes)

Effective DateJan 1, 2020

Next Review Date

SourceLink

On This Page

OpenPayer

Vancocin – Prior Authorization/Notification (PDF)

Coverage Summary

Initial Therapy Criteria

Continuation / Reauthorization Criteria

Staphylococcal Enterocolitis Criteria

Provider Actions & Authorization Rules

Applicable Codes

Clinical Evidence & Definitions

Background

Revision History