Cayston Prior Authorization Criteria - Medicare Part D

Prior Authorization Criteria for Approval

Cayston will be approved when ALL of the following are met: 

1. The patient has a diagnosis of cystic fibrosis
   AND
2. Documentation has been provided that indicates the patient has a Pseudomonas aeruginosa respiratory infection
   AND
3. ONE of the following:
   1. The patient is NOT currently (within the past 60 days) being treated with another inhaled antibiotic (e.g., inhaled tobramycin)
      OR
   2. The patient is currently (within the past 60 days) being treated with another inhaled antibiotic (e.g., inhaled tobramycin) AND ONE of the following:
      1. The prescriber has confirmed that the other inhaled antibiotic will be discontinued, and that therapy will be continued only with the requested medication
         OR
      2. The prescriber has provided information in support of another inhaled antibiotic therapy used concurrently with or alternating with (i.e., continuous alternating therapy) the requested medication

Length of Approval: 12 months