amphotericin B — CareFirst (Caremark)

Initial criteria

• The requested drug will NOT be used intranasally or in a footbath
• The requested drug is being prescribed for an FDA-approved indication or an indication supported in the compendia of current literature (examples: AHFS, Micromedex, current accepted guidelines)
• The infection is proven or strongly suspected to be caused by susceptible microorganisms
• The patient meets ONE of the following: the patient cannot be treated with oral therapy OR the request is for vancomycin to be taken orally for the treatment of C. difficile associated diarrhea or for staphylococcal enterocolitis

Approval duration

serious, chronic, recurring infection: 12 months; other indications: 3 months