Limited coverage criteria – aztreonam

Last updated on March 17, 2025

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Generic name	aztreonam
Strength & form	75 mg/ml 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

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)

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HLTH 5328 - General Special Authority request (PDF, 656KB)

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