Limited Coverage Drugs - Aztreonam

Generic Name

aztreonam

Strength

75 mg/ml
Form Vial-Neb

Special Authority Criteria

Approval Period

For the cyclic treatment of chronic Pseudomonas aeruginosa infections in patients with:

Moderate to severe cystic fibrosis

AND

A deteriorating clinical condition despite treatment with inhaled tobramycin.

Indefinite

Practitioner Exemptions

  • None

Special Notes

  • Cyclic treatment is measured in 28-day cycles and is defined as 28 days “on” aztreonam followed by 28 days “off.”
  • Aztreonam may be prescribed either as monotherapy or as a combination treatment with another therapy chosen by the prescribing physician.
  • Aztreonam is a PharmaCare high-cost drug. PharmaCare reimburses high-cost drugs eligible for coverage to a maximum price based on the manufacturer list price plus a 5 percent mark-up.

Special Authority Request Form(s)