Furoscix — Blue Cross Blue Shield of Alabama

edema with chronic kidney disease (including nephrotic syndrome)

Initial criteria

Diagnosis of edema with chronic heart failure or chronic kidney disease (including nephrotic syndrome) AND BOTH of the following:
ONE of the following: • Creatinine clearance (CrCl) ≥ 30 mL/min OR • Estimated glomerular filtration rate (eGFR) ≥ 20 mL/min/1.73m^2
AND BOTH of the following: • Patient was treated with an oral loop diuretic total daily dose of 40–160 mg furosemide equivalent AND • Patient will NOT use the requested agent in combination with another loop diuretic and will transition back to oral diuretic therapy after completion of the requested agent
OR • Patient has another FDA labeled indication for the requested agent and route of administration
If the patient has an FDA labeled indication, then ONE of the following: • Patient’s age is within FDA labeling for the requested indication OR • There is support for using the requested agent for the patient’s age for the requested indication
Prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, nephrologist), or has consulted with such a specialist
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months