Health Net
Ozobax (baclofen)
Drugs for Muscles, Ligaments, Tendons, and Bones : Drugs for Muscles, Ligaments, Tendons, and Bones
  • Prior Authorization: Documented Diagnosis: Yes
    Age Requirement: >= 12
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Step Therapy: ST Single Generic

  • Limb Spasticity:
    Age Requirement: >= 12
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedic Specialist;Physiatrist;Physical Medicine & Rehabilitation Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Pediatric Upper Limb Spasticity:
    Age Requirement: >= 12
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedist;Physiatrist;Rehabilitation specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Spasticity: Adult, Spasticity: Lower Limb, Spasticity: Upper Limb:
    Age Requirement: >= 12
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Neurologist;Orthopedist;Physical Therapist;Rehabilitation specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

<< Return | Back to top