- Prior Authorization: Chronic Heart Failure (CHF):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Chronic Heart Failure (CHF):
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Cardiologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Quantity Limit: limit maximum 2 EA PER 1 day(s)
- Step Therapy: Chronic Heart Failure (CHF):
ST Single Generic
|