- Gastro: IBS-D:
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: No
REMs Program Criteria Included: No
Policy States Patient Must Have a Documented Trial and Failure of Diet, Exercise and Counseling: No
Documented Diagnosis: No
Chronic IBS Symptoms for 6 Months or Longer: No
Non-pharmacologic Therapy: No
Patient Must Have Documented Symptoms of Loose Watery Stools: No
Hepatic Encephalopathy (HE):
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: No
Documented Diagnosis: No
- Prior Authorization: PA_APPLIES
- Quantity Limit: limit maximum 1 ML PER 84 day(s)
- ST_APPLIES
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