Limited Use Note(s)
MOMETASONE FUROATE & FORMOTEROL FUMARATE DIHYDRATE
200mcg & 5mcg Metered Dose Inh-120 Dose Pk
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Reason For Use Code
Clinical Criteria
330
For the treatment of asthma in patients who are using optimum anti-inflammatory treatment and are still experiencing breakthrough symptoms.
LU Authorization Period: Indefinite.
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