- Step Therapy: Chronic Kidney Disease:
ST Single Brand
- Prior authorization required. Member should try alternative(s) before submitting a prior authorization. If approved, covered at appropriate tier under the member's pharmacy benefit.
- Prior Authorization: Chronic Kidney Disease:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 3 Month(s)
Reauthorization Required: Yes
- Chronic Kidney Disease:
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Cardiologist;Endocrinologist;Nephrologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
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