CurrentMississippi Division of MedicaidPolicy N/A

FUROSCIX (furosemide) — Prior Authorization Coverage Criteria

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Defines prior authorization requirements, clinical criteria, dosing, and quantity limits for FUROSCIX (on-body furosemide infusor) for Mississippi Division of Medicaid members.

Policy Summary

PayerMississippi Division of Medicaid

PolicyFUROSCIX (furosemide) — Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionSubmit a Universal PA Form with supporting clinical documentation demonstrating diagnosis, prior trial of an oral loop diuretic, specialist involvement, and prescriber attestation for short-term use.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4initial quantity limit per claim

1 monthtime limit for initial authorization

30 mg → 12.5 mg/hrdosing regimen

80 mg/10 mLformulation concentration

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CurrentMississippi Division of MedicaidPolicy N/A

FUROSCIX (furosemide) — Prior Authorization Coverage Criteria

Customize your policy alerts

Sign up for all Mississippi Division of Medicaid policy alerts

Know when Mississippi Division of Medicaid releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines prior authorization requirements, clinical criteria, dosing, and quantity limits for FUROSCIX (on-body furosemide infusor) for Mississippi Division of Medicaid members.

Policy Summary

PayerMississippi Division of Medicaid

PolicyFUROSCIX (furosemide) — Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4initial quantity limit per claim

1 monthtime limit for initial authorization

30 mg → 12.5 mg/hrdosing regimen

80 mg/10 mLformulation concentration

Coverage Criteria for FUROSCIX

Initial Authorization

Covered when ALL of the following are met:

Age of the patient is within the age range as recommended by the FDA labelper FDA label

Diagnosis of congestive heart failure or chronic kidney disease

includes nephrotic syndrome as noted in indication

Clinical signs: Documentation that patient is showing signs or symptoms of fluid overload due to congestive heart failure or chronic kidney disease (e.g., rapid weight gain, jugular venous distension, pitting edema, abdominal distention, pulmonary rales)

Prior diuretic trial: Patient has been stable and is refractory to at least one of the following oral loop diuretics at up to maximally indicated doses: furosemide, torsemide, bumetanide, or ethacrynic acidmaximally indicated doses

Specialist involvement: Prescribed by or in consultation with a specialist in the area of the patient's diagnosis (e.g., cardiologist or nephrologist)

Prescriber attestation: Prescriber attests that: the patient is a candidate for parenteral diuresis outside the hospital; FUROSCIX will be used short-term and the patient will be transitioned to oral diuretics as soon as practical; and the patient will be educated on proper Infusor placement and instructions for starting the infusion

All attestations required

FUROSCIX® is indicated for treatment of edema in adults with chronic heart failure or chronic kidney disease, including nephrotic syndrome, but is not for chronic use. Prior authorization is required; initial authorization is limited to ≤ 4 single‑dose prefilled cartridges per claim with a 1‑month time limit. Requests that exceed these quantity or time limits must include justification and documentation outlining a plan to transition the patient to oral diuretics.

Prescribers must attest that the patient is a candidate for parenteral diuresis outside the hospital, that FUROSCIX will be used short‑term only, and that the patient will be transitioned to oral diuretics as soon as practical. Provide documentation of age per the FDA label, diagnosis of congestive heart failure or chronic kidney disease, clinical signs of fluid overload, and prior trial and refractory response to at least one oral loop diuretic at maximally indicated doses.

Coding and Quantity Limits

No codes listedmixed

No codes listed

Initial authorization quantity/time

Quantity per claim≤ 4 single-dose prefilled cartridges per claim

Time limit (initial authorization)≤ 1 month

Exceedance documentationRequests exceeding limits require justification and a plan to transition to oral diuretics

Provider Requirements and Prior Authorization

Prior Authorization

Prior authorization required — submit Universal PA Form and clinical documentation

Prior authorization is required for FUROSCIX. Submit the Universal PA Form with the initial authorization request; include supporting clinical documentation as specified for initial review. Initial authorization is limited to 4 single‑dose prefilled cartridges per claim with a 1‑month time limit.

Use Universal PA Form for submission
Initial authorization = ≤4 cartridges per claim; time limit = 1 month

Step Therapy

Required trial of ≥1 oral loop diuretic prior to approval

Patient must be stable and refractory to at least one oral loop diuretic (furosemide, torsemide, bumetanide, or ethacrynic acid) at up to maximally indicated doses before FUROSCIX will be approved.

Acceptable prior oral loop diuretics: furosemide, torsemide, bumetanide, ethacrynic acid

Background

FUROSCIX is a single‑use, on‑body infusor that delivers parenteral furosemide for the treatment of edema in adults with chronic heart failure or chronic kidney disease, including nephrotic syndrome. The device is co‑packaged with a prefilled cartridge and provides a preprogrammed infusion regimen to enable parenteral diuresis outside the hospital setting; it is intended for short‑term outpatient use and should be followed by transition to oral diuretics.

Definitions

FUROSCIX key facts

Device typeSingle-use on-body infusor co-packaged with a prefilled cartridge

Cartridge concentration80 mg / 10 mL (8 mg/mL) furosemide

Dosing regimen (programmed)30 mg over the first hour, followed by 12.5 mg per hour for the subsequent 4 hours

PackagingSingle-dose prefilled cartridge provided with one On-Body Infusor

Intended useProvides parenteral diuresis outside the hospital for short-term management of edema in adults with chronic heart failure or chronic kidney disease

Documentation Required

Supporting clinical documentation required with PA submission

Along with the Universal PA Form, include documentation demonstrating age per the FDA label; diagnosis of congestive heart failure or chronic kidney disease; signs/symptoms of fluid overload; prior diuretic trial and refractory response; specialist involvement or consultation; and the prescriber’s attestations regarding short‑term use, candidacy for outpatient parenteral diuresis, and patient education on Infusor placement and initiation.

Patient age per FDA label
Diagnosis: congestive heart failure or chronic kidney disease (includes nephrotic syndrome)
Clinical signs of fluid overload (e.g., rapid weight gain, JVD, pitting edema, abdominal distention, pulmonary rales)
Documentation of trial and refractory response to at least one oral loop diuretic at maximally indicated doses
Prescribed by or in consultation with a specialist (e.g., cardiologist or nephrologist)
Prescriber attestation: candidate for parenteral diuresis outside hospital; FUROSCIX short‑term with transition to oral diuretics; patient education on Infusor placement and starting the infusion