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

  • None

Special Notes

  1. Vancomycin capsules are a full benefit for patients registered with the Palliative program.
  2. Prescribers may submit written requests via the Special Authority fax line at any time. A coverage decision should be provided within one business day.
  3. Urgent Special Authority requests can be made:
    • if the patient meets any of the criteria. The prescriber can contact the Special Authority line Monday to Friday, 8:00 a.m. to 4:00 p.m. (excluding statutory holidays), to request authorization; or
    • after hours, if a patient meets any of the criteria, a prescriber can contact the PharmaNet Help Desk (available 24 hours per day, 7 days per week) to request initial urgent Special Authority for vancomycin. All requests for renewal of existing coverage must be made through Special Authority via fax or phone during regular business hours.
    • pharmacists may request Special Authority coverage for vancomycin being dispensed following a hospital stay.  For more information regarding when pharmacists can request Special Authority, please see: Limited Coverage Drugs: information for pharmacies.

Special Authority Request Form(s)