Prior Authorization Criteria for Approval

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

1. The patient has an FDA labeled indication for the requested agent AND ONE of the following:
   1. The requested medication is prescribed by an infectious disease specialist or the prescriber has consulted with an infectious disease specialist on treatment of this patient
      OR
   2. The patient has a documented infection due to vancomycin-resistant Enterococcus faecium
      OR
   3. The patient has a diagnosis of pneumonia caused by Staphylococcus aureus or Streptococcus pneumoniae AND ONE of the following:
      1. The patient has a documented infection that is resistant to at least two of the following: beta-lactams, macrolides, clindamycin, tetracyclines, or co-trimoxazole, OR that is resistant to vancomycin
         OR
      2. The patient has an intolerance or hypersensitivity to at least two of the following: beta-lactams, macrolides, clindamycin, tetracyclines, or co-trimoxazole
         OR
      3. The patient has an FDA labeled contraindication to at least two of the following: beta-lactams, macrolides, clindamycin, tetracyclines, or co-trimoxazole
         OR
      4. The patient has an intolerance or hypersensitivity to vancomycin
         OR
      5. The patient has an FDA labeled contraindication to vancomycin
         OR
   4. The patient has a documented skin and skin structure infection, including diabetic foot infections, caused by Staphylococcus aureus, Streptococcus pyogenes, or Streptococcus agalactiae AND ONE of the following:
      1. The patient has a documented infection that is resistant to at least two of the following: beta-lactams, macrolides, clindamycin, tetracyclines, or co-trimoxazole, OR that is resistant to vancomycin at the site of infection
         OR
      2. The patient has an intolerance or hypersensitivity to at least two of the following: beta-lactams, macrolides, clindamycin, tetracyclines or co-trimoxazole
         OR
      3. The patient has an FDA labeled contraindication to at least two of the following: beta-lactams, macrolides, clindamycin, tetracyclines, or co-trimoxazole
         OR
      4. The patient has an intolerance or hypersensitivity to vancomycin
         OR
      5. The patient has an FDA labeled contraindication to vancomycin
         AND
2. The patient will NOT be using the requested medication in combination with Sivextro (tedizolid) for the same infection
   AND
3. The patient does NOT have any FDA labeled contraindications to the requested medication
   AND
4. The requested dose is within FDA labeled dosing for the requested indication

Length of Approval: 3 months