Vancomycin (Vancocin HCL) Prior Authorization Criteria

General Prior Authorization Request Form

Covered Uses

• Enterocolitis caused by Staphylococcus aureus (including methicillin-resistant strains)
  
• Antibiotic-associated pseudomembranous colitis caused by C. difficile.

Exclusion Criteria

(a) None

Required Medical Information

(a) None

Age Restrictions

(a) None

Prescriber Restrictions

(a) None

Coverage Duration

Approved for 15 day supply according to prescription and dosing parameters

Other Criteria

(a) None