furosemide subcutaneous cartridge kit — Blue Cross Blue Shield of Montana

other FDA labeled indication for requested agent and route of administration

Initial criteria

ONE of the following:
A. The patient has a diagnosis of edema with chronic heart failure or chronic kidney disease (including nephrotic syndrome) AND BOTH of the following:
1. The patient was treated with an oral loop diuretic total daily dose of 40–160 mg furosemide equivalent AND
2. The patient will NOT be using the requested agent in combination with another loop diuretic and will transition back to oral diuretic therapy after completion of the requested agent OR
B. The patient has another FDA labeled indication for the requested agent and route of administration AND
If the patient has an FDA labeled indication, then ONE of the following:
A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
B. There is support for using the requested agent for the patient’s age for the requested indication AND
The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, nephrologist), or has consulted with such a specialist AND
The patient does NOT have any FDA labeled contraindications to the requested agent

12 months