Sutter Health Plus
CeleXA (citalopram)
Drugs for the Nervous System : Drugs for Depression
  • QL (1 per Rx);
  • Alpha-1 Antitrypsin Deficiency:
    Duration: 1 year(s)
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Required Evidence of Emphysema: No
    Documented Serum AAT Level: N/A
    Policy Required Patient Must be a Non-smoker: No
    Documented Diagnosis: No

  • Low Testosterone:
    Age Requirement: >= 18
    Duration: 1 year(s)
    Gender Requirement: Male
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    How Many Tests are Required to Confirm Diagnosis: >= 1
    Serum Total Testosterone Test Results: Variable
    Free Testosterone Level Test Results: Unspecified
    Patient must have symptoms of hypogonadism: Yes
    Patient history of condition that may cause altered SHBG: No
    Patient Must Not Have Untreated Sleep Apnea, Polycythemia or CHF: Yes
    Supporting Documentation Requirements: Medical Tests
    Reauthorization Supporting Documentation Requirements: Medical Tests
    Diagnosis of Primary Hypogonadism or Hypogonadotropic Hypogonadisims: Yes
    Documented Diagnosis: Yes