Health Net
Tobi (tobramycin in 0.225 % NaCl)
Drugs for the Lungs : Drugs for Cystic Fibrosis
  • Step Therapy: Cystic Fibrosis (CF):
    ST Single Generic

  • Prior Authorization: Cystic Fibrosis (CF):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 6
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Must use AcariaHlth Sp Rx
  • Cystic Fibrosis (CF):
    Age Requirement: >= 6
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): 1 of CF Specialist;Infectious Disease Specialist;Pulmonologist
    Reauthorization Required: Yes
    Duration of Reauthorization: <= 12 month(s)
    Documented Mutation in the CFTR Gene: No
    Documented Homozygous F508del Mutation in the CFTR Gene: No
    Pseudomonas Aeruginosa Culture Required: Yes
    Baseline FEV1 Value (percent predicted): N/A
    FEV1 ImprovementMaintenance for Reauthorization: No
    Liver Function Test Required: No

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