| Anthem Blue Cross (HMO, PPO, EPO) |
| Bethkis (tobramycin) |
| Drugs for the Lungs : Drugs for Cystic Fibrosis |
- Cystic Fibrosis (CF):
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Documented Mutation in the CFTR Gene: No
Documented Homozygous F508del Mutation in the CFTR Gene: No
Pseudomonas Aeruginosa Culture Required: No
Baseline FEV1 Value (percent predicted): N/A
FEV1 ImprovementMaintenance for Reauthorization: No
Liver Function Test Required: No
- Quantity Limit: limit maximum 224 mL PER 28 day(s)
- Step Therapy: Cystic Fibrosis (CF):
ST Multiple Generics
- Available only through Specialty Pharmacy;
- Prior Authorization: Cystic Fibrosis (CF):
Duration: 1 year(s)
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