Limited Coverage Drugs - Vancomycin

Generic Name

vancomycin

Strength

125 mg, 250 mg
Form capsule

Special Authority Criteria

Approval Period

For the treatment of symptomatic Clostridium Difficile Infection (CDI), when:

  1. The patient is allergic, resistant, or intolerant to metronidazole.

    OR
     
  2. The patient has failed to respond to 4–6 days of oral metronidazole at doses of 500 mg three times per day.

    OR
     
  3. The patient has symptoms of moderate to severe disease or is experiencing a second disease recurrencei

    OR
     
  4. The patient was initiated on vancomycin as an inpatient (e.g., in a hospital setting, nursing home, or long-term care facility) and requires continuation of vancomycin to complete their full course of therapy.

Initial: up to 14 days

Second or further recurrence: up to 14 days
 

Practitioner Exemptions

  • Urgent Special Authority requests can be made by prescribers and pharmacists:
    • Monday to Friday, 8:00 a.m. to 4:00 p.m., prescribers can submit requests via the usual Special Authority process and indicate the request is urgent. A coverage decision should be provided within 24 hours.
    • After hours, if a patient meets any of the criteria above, a prescriber or pharmacist can contact the PharmaNet HelpDesk to request urgent Special Authority for vancomycin.
    • The HelpDesk is available 24 hours per day, 7 days per week.

Special Notes

  1. Recurrence is defined as a subsequent CDI episode occurring within 2–8 weeks of the date of diagnosis of a previous episode.

Special Authority Request Form(s)