Furoscix (furosemide subcutaneous 80 mg/10 mL cartridge kit) — Blue Cross Blue Shield of New Mexico

Edema with chronic heart failure

Initial criteria

1. 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
2. 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
3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, nephrologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
4. The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization will follow the same clinical criteria as initial approval; length of approval 12 months.

12 months