Limited Use Note(s) |
|
MIDAZOLAM5mg/mL Inj Sol (with Preservative)
| Reason For Use Code | Clinical Criteria |
|---|---|
| 495 | For intermittent injection used for symptomatic relief in patients receiving palliative care*. |
| LU Authorization Period: 1 year | |
| NOTE: *The patient must have a progressive life-limiting illness and require this medication for palliative purposes. | |
| 496 | For continuous infusion in patients receiving palliative sedation*. |
| LU Authorization Period: 1 year | |
| NOTE: *The patient must have a progressive life-limiting illness and require this medication for palliative purposes. |