- Primary Biliary Cirrhosis and Hepatic Fibrosis:
Duration: 6 Month(s)
Specialist Required: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Gastroenterologist;Hepatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
How Many Tests are Required to Confirm Diagnosis: N/A
Alkaline Phosphatase (ALP) Level Required: Unspecified
Total Bilirubin Required: N/A
Patient Must Not Have Clinically Significant Hepatic Decompensation: No
Inadequate Response to Ursodiol Can Not Be Due to Non-Compliance: No
Policy states the patient must not have other liver disease that is not related to PBC: No
Must Not Have Complete Biliary Obstruction: No
Concomitant Use of Ursodiol Required: Yes
Duration of Ursodiol Without Adequate Response: = 12 month(s)
Patient Must Not Be Experiencing Severe Pruritis: No
Reauthorization Supporting Documentation Requirements: 1 of Chart Notes;Medical Tests
Documented Diagnosis: Yes
- Step Therapy: Primary Biliary Cirrhosis and Hepatic Fibrosis:
ST Single Generic
- Prior Authorization: Primary Biliary Cirrhosis and Hepatic Fibrosis:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
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