Medical Policy

Effective Date:04/01/2019 Title:Aemcolo (rifamycin)
Revision Date: Document:BI603:00
CPT Code(s):
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)    Aemcolo (rifamycin) requires prior authorization.

2)    Aemcolo is used to treat travelers’ diarrhea caused by noninvasive strains of Escherichia coli in adults.

3)    Aemcolo is covered under the pharmacy benefit.

Medical Statement

Aemcolo (rifamycin) is considered medically necessary for patients meeting ALL of the following conditions:

1)    Patient is 18 years of age or older AND

2)    Patient has a diagnosis of Travelers’ diarrhea (TD) AND

3)    Diarrhea is not accompanied by fever or bloody stool AND

4)    One of the following:

a.    Trial and failure to one of the following:

                                          i.    Azithromycin

                                        ii.    Ciprofloxacin

                                       iii.    Levofloxacin

                                       iv.    Ofloxacin

b.    Resistance, contraindication, or intolerance to all of the following antibiotics:

                                          i.    Azithromycin

                                        ii.    Ciprofloxacin

                                       iii.    Lefofloxacin

                                       iv.    Ofloxacin

Limits

1)    The recommended dosage is two (2) tablets twice daily for three (3) days.  Consequently, Aemcolo is limited to a maximum quantity of 12 tablets per 180 days.

Reference

1)    Aemcolo Prescribing Information. Cosmo Technologies, Ltd. San Diego, CA. November 2018.

2)    Riddly MS, Connor BA, Beeching NJ, et al. Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report. J Travel Med. 2017;24(suppl 1):S63-S80.

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.