Limited Use Note(s)

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VALGANCICLOVIR50mg/mL Pd for Oral Sol-100mL Pk
Reason For Use CodeClinical Criteria
571For those unable to swallow or tolerate solid oral dosage form AND For the treatment of Cytomegalovirus (CMV) retinitis in patients with HIV/AIDS.
LU Authorization Period: 1 year
572For those unable to swallow or tolerate solid oral dosage form AND For the prevention of Cytomegalovirus (CMV) in solid organ transplant patients (not lung or heart-lung).
LU Authorization Period: Up to 6 months
573For those unable to swallow or tolerate solid oral dosage form AND For the prevention of Cytomegalovirus (CMV) in lung or heart-lung transplant patients.
LU Authorization Period: Up to 12 months