- Quantity Limit: limit maximum 20 EA PER 1 day(s)
- Cystic Fibrosis (CF):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
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: No
Baseline FEV1 Value (percent predicted): N/A
FEV1 ImprovementMaintenance for Reauthorization: No
Liver Function Test Required: No
- Prior Authorization: Cystic Fibrosis (CF):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
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