metronidazole 125 mg tablet — Highmark
Trichomoniasis
Preferred products
- generic metronidazole tablets (not including 125 mg tablets)
Initial criteria
- age ≥ 18 years if the diagnosis is for trichomoniasis or anaerobic bacterial infection
- diagnosis of one of the following (a., b., or c.): a. Trichomoniasis (ICD-10: A59.9) b. Amebiasis (ICD-10: A06.9) c. Anaerobic bacterial infection (ICD-10: A41.4)
- experienced therapeutic failure or intolerance to plan-preferred, generic metronidazole tablets (not including 125 mg tablets)
Reauthorization criteria
- prescriber attests member has a repeat episode of one of the following: a. Trichomoniasis (ICD-10: A59.9) b. Amebiasis (ICD-10: A06.9) c. Anaerobic bacterial infection (ICD-10: A41.4)
- for recurrent trichomoniasis, at least 4 weeks have passed since the member finished the first course of metronidazole 125 mg tablets
- member has experienced therapeutic failure or intolerance to plan-preferred, generic metronidazole tablets (not including 125 mg tablets)
Approval duration
up to 7 days for trichomoniasis; up to 10 days for amebiasis; up to 3 months for anaerobic infections