Limited Use Note(s)
CIPROFLOXACIN HCL & CIPROFLOXACIN BASE
500mg ER Tab
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Reason For Use Code
Clinical Criteria
394
For patients with uncomplicated urinary tract infections (acute cystitis) who have failure, intolerance or hypersensitivity to all formulary antibiotic alternatives that are listed as General Benefits.
LU Authorization Period: 1 year
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