- Health Net Approved Indications and Usage Guidelines: 1. Diagnosis of chronic heart failure of NYHA (New York Heart Association) Class II-IV. AND 2. Prescribed by or in consultation with a Cardiologist. AND 3. Left ventricular ejection fraction less than 40%. Authorization Limit: Length of Benefit.
- Prior Authorization: Chronic Heart Failure (CHF):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 1
Duration: 12 Month(s)
Reauthorization Required: Yes
- Chronic Heart Failure (CHF):
Age Requirement: >= 1
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 Brand
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