Limited Use Note(s)

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DALTEPARIN SODIUM15000IU/0.6mL Inj Pref Syr
Reason For Use CodeClinical Criteria
186For acute treatment of deep venous thrombosis (DVT), for a maximum of three weeks;
LU Authorization Period: 1 year
187For DVT in pregnant or lactating females;
LU Authorization Period: 1 year
188For DVT in patients whom treatment with warfarin is not tolerated, or contraindicated;
LU Authorization Period: 1 year
189For DVT in patients who have failed treatment with warfarin.
LU Authorization Period: 1 year