Currentsierra health and lifePolicy N/A

Vancocin (vancomycin) oral capsules prior authorization/notification

Defines prior authorization and notification requirements for coverage of oral vancomycin (Vancocin) for treatment of Clostridium difficile-associated diarrhea and staphylococcal enterocolitis for Sierra Health and Life members in NC.

Policy Summary

Payersierra health and life

PolicyVancocin (vancomycin) oral capsules prior authorization/notification

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionObtain prior authorization/notification and document diagnosis plus trial or contraindication/intolerance to Firvanq oral solution (or prescriber reason it cannot be used).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10 daysauthorization duration for staphylococcal enterocolitis

Initial + Reauthorizationdistinct criteria sections

12/2019, 12/2020P&T approval dates

1/1/2020program effective date

Coverage Criteria for Vancocin (oral vancomycin)

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Initial Authorization — CDAD

Covered when ALL of the following are met

Initial authorization for CDAD: 1) Diagnosis of Clostridium difficile-associated diarrhea (CDAD); AND 2) One of the following: (a) history of failure, contraindication, or intolerance to Firvanq (vancomycin) oral solution, OR (b) prescriber provides a reason or special circumstance the patient cannot use Firvanq (vancomycin) oral solution.

Reauthorization — CDAD recurrence

Covered when ALL of the following are met

Reauthorization for CDAD: Recurrence of Clostridium difficile infection after prior treatment with vancomycin oral capsules.

Initial Authorization — Staphylococcal enterocolitis

Covered when ALL of the following are met

Staphylococcal enterocolitis authorization: 1) Diagnosis of enterocolitis caused by Staphylococcus aureus; AND 2) One of the following: (a) history of failure, contraindication, or intolerance to Firvanq (vancomycin) oral solution, OR (b) prescriber provides a reason or special circumstance the patient cannot use Firvanq (vancomycin) oral solution.

Authorization will be issued for 10 days.

Parenteral vancomycin is not effective for treatment of Clostridium difficile-associated diarrhea (CDAD) or staphylococcal enterocolitis. For these indications vancomycin must be administered orally; intravenous/parenteral routes are not a covered route for CDAD or staphylococcal enterocolitis.

Provider Actions, Documentation & Step Therapy

Prior Authorization

Prior authorization/notification required

Prior authorization/notification is required for Vancocin (vancomycin) oral capsules for treatment of C. difficile-associated diarrhea (CDAD) or staphylococcal enterocolitis. Authorization will be issued for 10 days when criteria are met.

Affected product: Vancocin (oral capsules)
Authorization duration: 10 days

Step Therapy

Preferred formulation requirement

Firvanq (vancomycin) oral solution is the preferred oral formulation. Members must trial Firvanq first unless there is documented history of failure, intolerance, or contraindication, or the prescriber documents a reason or special circumstance the patient cannot use Firvanq.

Preferred formulation: Firvanq (vancomycin) oral solution
Exceptions: documented history of failure, intolerance, contraindication, or prescriber-documented reason

Documentation Required

Required clinical documentation

For initial authorization of Vancocin oral capsules, submit documentation supporting the diagnosis and the applicable formulation exception: for CDAD, provide diagnosis of Clostridium difficile-associated diarrhea; for staphylococcal enterocolitis, provide diagnosis of enterocolitis caused by Staphylococcus aureus. Additionally, provide documentation of one of the following: (1) history of failure, contraindication, or intolerance to Firvanq (vancomycin) oral solution, or (2) prescriber documents a reason or special circumstance the patient cannot use Firvanq.

Required diagnosis: CDAD or staphylococcal enterocolitis (S. aureus)
Required supporting documentation: trial/failure/intolerance/contraindication to Firvanq OR prescriber-documented reason patient cannot use Firvanq

Denial Risk

Automated approval/denial risk

Approvals (initial and reauthorization) may be made based solely on previous claim/medication history, diagnosis codes (ICD-10), and/or claim logic through automated approval processes. Supply limits may apply. Use of automated approval and re-approval processes varies by program and therapeutic class.

Automated approval/denial may use claims, medication history, diagnosis codes, and claim logic
Supply limits may be in place

Step	Requirement
1
Must have trial of Firvanq (vancomycin) oral solution, OR documentation of history of failure, contraindication, or intolerance to Firvanq, OR a prescriber-provided reason/special circumstance why the patient cannot use Firvanq before approval of Vancocin (vancomycin) oral capsules.

Background and Definitions

Oral vancomycin formulations included in this policy are Vancocin (vancomycin) oral capsules and Firvanq (vancomycin) oral solution. These oral products are indicated for treatment of Clostridium difficile-associated diarrhea (CDAD) and enterocolitis caused by Staphylococcus aureus (including methicillin-resistant strains). Because parenteral vancomycin is ineffective for these infections, oral administration is required when vancomycin is used for these indications.

CDAD definition

DefinitionCDAD = Clostridium difficile-associated diarrhea (also called Clostridioides difficile).

Also calledClostridioides difficile (alternate genus name).

Clinical contextOral vancomycin is indicated for treatment of CDAD; parenteral vancomycin is not effective for this infection.

Policy Summary

Payersierra health and life

PolicyVancocin (vancomycin) oral capsules prior authorization/notification

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionObtain prior authorization/notification and document diagnosis plus trial or contraindication/intolerance to Firvanq oral solution (or prescriber reason it cannot be used).

SourceLink

On This Page

OpenPayer

Vancocin (vancomycin) oral capsules prior authorization/notification

Coverage Criteria for Vancocin (oral vancomycin)

Provider Actions, Documentation & Step Therapy

Initial Therapy Requirements

Reauthorization / Continuation Criteria

Step Therapy Requirements

Site of Care and Route of Administration

Quantity Limits and Product Identification

Background and Definitions