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)

• Log in to eForms
• 5328 - General Special Authority Request (PDF, 656KB)