- Prior Authorization: PA_APPLIES
- Quantity Limit: 6 tablets per 1 day(s).
- Zero copay may apply.
- Step Therapy: ST_APPLIES
- Pain Narcotic: Opioid:
Age Requirement: >= 18
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Type(s): Chronic Pain
Used for Cancer Patients: No
Around-The-Clock Analgesic Required: No
Morphine Equivalent Dose (MED) Limit: N/A
Morphine Equivalent Dose (MED) Required: No
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