- Post-herpetic Neuralgia:
Age Requirement: >= 18
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
- Health Net Approved Indications and Usage Guidelines: 1. Diagnosis of postherpetic neuralgia (shingles or herpes zoster). AND 2. Failure or clinically significant adverse effects to a gabapentin dose greater than or equal to 1,200 mg/day. Authorization Limit: Length of benefit.
- Step Therapy: Post-herpetic Neuralgia:
ST Single Generic
- Quantity Limit: limit maximum 3 EA PER 1 day(s)
- unspecified ST criteria Step Therapy Exists in PA
- Prior Authorization: Post-herpetic Neuralgia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
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