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)