Medical Policy

Effective Date:10/03/2012 Title:Cayston (Aztreonam)
Revision Date:10/01/2015 Document:BI376:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Cayston (Aztreonam) requires prior authorization.

2)    Cayston is approved for use to improve the respiratory symptoms in cystic fibrosis. patients with Pseudomonas aeruginosa and an FEV1 between 25 – 75% predicted.

3)    Cayston is covered under the pharmacy benefit as a specialty drug.

Medical Statement

Cayston (Aztreonam) is considered medically necessary for patients who meet all the following criteria.  Initial approval will be for 28 days. 

1)    Diagnosis of cystic fibrosis (CF)   (E84.0) AND

2)    Patient colonized with Pseudomonas aeruginosa (confirmed by culture)  (B96.5) AND

3)    FEV1  >25% to <75% predicted   AND

4)    Patient > 7 years of age.

Limits

Cayston is limited to no more than a 30 day supply per fill.

Reference

1)    Cayston Product Information.  Gilead Sciences, Inc.  2010.

2)    Clinical Pharmacology.  Cayston accessed online September 2012.

3)    Retsch-Bogart G, Quittner A, Gibson R, et al.  Efficacy and Safety of Inhaled Aztreonam Lysine for Airway Pseudomonas in Cystic Fibrosis.  Chest 2009; 135(5):1123-1232.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.