- Idiopathic Pulmonary Fibrosis (IPF):
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Pulmonologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Policy requires patient to be non-smoker: No
Evidence required for non-smoker: No
FVC % Value in Policy: N/A
Carbon Monoxide Diffusion Capacity (DLCO): N/A
Patient Must Not Have End Stage Renal Disease (ESRD) or Severe Hepatic Impairment: No
Reapproval criteria includes that the patient has less than 10% decrease in FVC: No
ESRD or severe hepatic impairment criteria: No
- Quantity Limit: limit maximum 9 EA PER 1 day(s)
- Prior Authorization: Idiopathic Pulmonary Fibrosis (IPF):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
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