- Quantity Limit: limit maximum 2 EA PER 1 day(s)
- Prior Authorization: Pain Narcotic: Opioid:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Pain Narcotic: Opioid:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Type(s): Severe Pain
Used for Cancer Patients: Yes
Around-The-Clock Analgesic Required: Yes
Morphine Equivalent Dose (MED) Limit: N/A
Morphine Equivalent Dose (MED) Required: No
|