UnitedHealthcare - 2014 to Present |
Kitabis Pak (tobramycin with nebulizer) |
Drugs for the Lungs : Drugs for Cystic Fibrosis |
- Crohn's Disease (CD):
Age Requirement: >= 6
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
Hidradenitis Suppurativa (HS): Age Requirement: >= 12
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): CVS Specialty
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Ulcerative Colitis (UC): Age Requirement: >= 5
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
- Neutropenia:
Duration: 1 year(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Risk Factor for Developing Febrile Neutropenia (FN): 1 of Age greater than 65 years;Bone marrow involvement;Extensive prior chemotherapy/radiation therapy;Liver dysfunction;Open wounds;Poor performance status;Poor renal function;Pre-existing neutropenia
Documented Diagnosis: Yes
Criteria includes risk factor for developing FN: Yes
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