Sivextro® (tedizolid)

Authorization forms

Tablet and Injection:

Traditional & Optimized (09/2018)

Medicaid (05/2018)

Tablet only (No PA required for injection under Part B benefit):

Medicare Part D (01/2019)

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J309

Benefit: Medical

Notes: Treatment of acute bacterial skin and skin structure infections