Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
vancomycin oral

Criteria Approval Period
Diagnosis of Clostridium Difficile Induced Colitis (CDIC)
PLUS
one of the following:

1. Patient has failed to respond to metronidazole.
2. The organism is resistant to metronidazole.
3. Patient is unable to tolerate metronidazole, or is allergic to it, or is being treated with ethanol containing solutions.
4. Patient is either pregnant or is a child under 10 years of age.
5. Patient is critically ill due to CDIC.

 Up to fourteen days.

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Important: As this medication may be required urgently, PharmaNet HelpDesk Customer Service Representatives are authorized to enter a Special Authority for vancomycin for a patient when a physician or pharmacist validates that one of the five criteria listed applies. The HelpDesk is available 24 hours a day, seven days a week.

Online Forms (PDF)
Click on the link to complete a special authority request form.