Limited Use Note(s)

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INSULIN GLARGINE100U/mL Inj Sol-10mL Vial Pk
Reason For Use CodeClinical Criteria
642Patient established on therapy prior to March 31, 2023 who is or has become pregnant during the biosimilar transition period between March 31, 2023 to December 28, 2023.
LU Authorization Period: One period of up to 12 months
643Patient established on therapy prior to March 31, 2023 who is or becomes palliative requiring end-of-life care during the biosimilar transition period between March 31, 2023 to December 28, 2023.
LU Authorization Period: One period of up to 12 months
644Patient requires insulin therapy and is unable to use the insulin pen.
LU Authorization Period: 1 year