Flucytosine Prior Authorization Criteria - Medicare Part D

Prior Authorization Criteria for Approval

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

1. The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested medication
   AND
2. ONE of the following:
   1. The requested medication will be used in combination with amphotericin B
      OR
   2. The prescriber has provided information in support of therapy without concurrent amphotericin B for the requested indication
      AND
3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., infectious disease) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
   AND
4. The patient does NOT have any FDA labeled contraindications to the requested medication
   AND
5. The requested dose is within FDA labeled dosing or supported in CMS approved compendia dosing for the requested indication

Length of Approval: 10 weeks