Zyvox (linezolid tablets and oral suspension) — Cigna

Initial criteria

• Methicillin-Resistant Staphylococcus Species Infection, Treatment: Approve for 1 month.
• Vancomycin-Resistant Enterococcus Species Infection, Treatment: Approve for 1 month.
• Continuation of Linezolid Therapy: Approve for 1 month if ONE of the following (A or B) is met: A) Patient is transitioning from intravenous (IV) linezolid or IV vancomycin to oral linezolid therapy; OR B) Patient was started on oral linezolid in an inpatient facility and is continuing therapy.
• Treatment of an Infection that is Resistant to Other Antibiotics, but the Organism is Sensitive to Linezolid: Approve for 1 month.
• Insufficient Information Available to Make a Determination and the prescriber or representative cannot be contacted: Approve for up to 2 weeks of therapy.
• Tuberculosis: Approve for 9 months if ALL of the following (A, B, and C) are met: A) Patient age ≥ 18 years; AND B) Patient meets ONE of the following (i, ii, or iii): i. Patient has extensively drug-resistant tuberculosis; OR ii. Patient has treatment-intolerant tuberculosis; OR iii. Patient has nonresponsive multidrug-resistant tuberculosis; AND C) Linezolid is prescribed in combination with Sirturo (bedaquiline tablets) and Pretomanid tablets.

Approval duration

1 month (except where noted: 2 weeks or 9 months as specified)