- Quantity Limit: limit maximum 2 EA PER 1 day(s)
- Prior Authorization: Idiopathic Pulmonary Fibrosis (IPF):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Health Net Approved Indications and Usage Guidelines: 1. Diagnosis of idiopathic pulmonary fibrosis. AND 2. Prescribed by or in consultation with a pulmonologist. Authorization Limit: Length of Benefit.
- Idiopathic Pulmonary Fibrosis (IPF):
Age Requirement: >= 18
Duration: 6 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: Yes
Evidence required for non-smoker: Yes
FVC % Value in Policy: >= 50
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
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