Limited Coverage Drugs - Prostaglandin Compounded Injection

Generic Name / Strength / Form

prostaglandin compounded injection

Criteria

Approval Period

Erectile dysfunction that occurs as a result of vascular or neurological damage that precludes adequate filling of the sinusoidal spaces.

Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

Special Authority Request Form(s)