Pulmozyme — Highmark
cystic fibrosis (CF)
Initial criteria
- Diagnosis of cystic fibrosis (ICD-10: E84)
- Prescriber attests that Pulmozyme will be used in conjunction with standard therapies (e.g., bronchodilators, hypertonic saline, antibiotics, anti-inflammatory therapy, CFTR modulators, pancreatic enzymes)
Reauthorization criteria
- Prescriber attests that the member experienced an increase in FEV1
- OR prescriber attests that the member experienced a decrease in the number of hospitalizations
- OR prescriber attests that the member experienced a decrease in the number of pulmonary exacerbations
Approval duration
up to 24 months