Dornase Alfa Inhalation Solution (Pulmozyme)

Pulmozyme (dornase alfa) is covered only for its FDA‑approved indication as adjunctive therapy for cystic fibrosis (off‑label/compendial uses are excluded); authorizations are issued for up to 12 months. Coverage requires documentation of confirmed cystic fibrosis, evidence the patient is receiving standard CF therapies, and—if claiming reduced respiratory infection risk—an FVC ≥ 40% predicted.

"Used in conjunction with standard therapies for the management of cystic fibrosis to improve pulmonary function."

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