Pharmacy Prior Authorization Criteria

Furoscix (furosemide injection) - PA, NF

For diagnosis of Edema
Indicated for the treatment of edema in adult patients with chronic heart failure or chronic kidney disease (CKD), including the nephrotic syndrome.

Prior Authorization

Length of Approval: 3 Month(s) [A]

AND

AND

Patient is currently on maintenance oral diuretic therapy (e.g., bumetanide, furosemide, torsemide) [C]

AND

Provider attests that patient will be closely monitored for fluid, electrolyte, and metabolic abnormalities throughout therapy (e.g., hypokalemia, hypovolemia, hyponatremia) [B]

Non Formulary

Length of Approval: 3 Month(s) [A]

Submission of medial records (e.g., chart notes) confirming diagnosis of one of the following:

AND

AND

Paid claims or submission of medical records (e.g., chart notes) confirming patient is currently on maintenance oral diuretic therapy (e.g., bumetanide, furosemide, torsemide) [C]

AND

Provider attests that patient will be closely monitored for fluid, electrolyte, and metabolic abnormalities throughout therapy (e.g., hypokalemia, hypovolemia, hyponatremia) [B]

2025-04-02, 2024-11-04, 2024-10-02, 2023-04-05, 2022-12-14

Furoscix Prescribing Information. scPharmaceuticals, Inc. Burlington, MA. March 2025.
scPharmaceuticals, Inc. A Multicenter, Randomized, Open Label, Controlled Study Evaluating the Effectiveness and Safety of Furoscix On-Body Infusor vs Continued Medical Therapy for Worsening Heart Failure. clinicaltrials.gov. Published May 3, 2022.
scPharmaceuticals, Inc. Economic Impact of Reducing Hospital Admissions for Patients Presenting to the Emergency Department With Worsening Heart Failure: An Adaptive Clinical Trial of Furoscix Infusor. clinicaltrials.gov. Published July 9, 2021.

Furoscix is not for chronic use and should be replaced with oral diuretics as soon as practical. [1]
Furosemide may cause fluid, electrolyte, and metabolic abnormalities such as hypovolemia, hypokalemia, azotemia, hyponatremia, hypochloremic alkalosis, hypomagnesemia, hypocalcemia, hyperglycemia, or hyperuricemia, particularly in patients receiving higher doses, patients with inadequate oral electrolyte intake, and in elderly patients. Serum electrolytes, CO , BUN, creatinine, glucose, and uric acid should be monitored frequently during furosemide therapy. [1]
Maintenance oral diuretic therapy includes those receiving 40-160 mg of oral furosemide equivalents daily (20-80 mg Torsemide or 1-4 mg Bumetanide). [3]

2025-04-02: Updated criteria due to expanded FDA indication and addition of submission of MR to diagnosis in NF criteria
2024-11-04: Annual review: No criteria changes.
2024-10-02: Updated guideline
2023-04-05: Addition of NF criteria
2022-12-14: New program