Limited Use Note(s)

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PENTOXIFYLLINE400mg SR Tab
Reason For Use CodeClinical Criteria
76 For the treatment of patients with critical limb ischemia (with arterial ulcers, gangrene and/or rest pain) and documented arterial vascular disease.
NOTE: Limited Use form must specify if arterial ulcers, gangrene and/or rest pain are present.
LU Authorization Period: Indefinite.
529For the treatment of patients with venous ulcers lasting, or expected to last, more than 8 weeks. Treatment should be discontinued after 3 months if there is no indication of objective benefit. The duration of therapy with pentoxifylline should not exceed 12 months.
NOTE: Pentoxifylline should be used in combination with compression therapy.
LU Authorization Period: 1 year