- Prior Authorization: Pain Narcotic: Opioid:
Documented Diagnosis: Yes
Duration: 1 Month(s)
- Pain Narcotic: Opioid:
Duration: 1 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Used for Cancer Patients: No
Around-The-Clock Analgesic Required: No
Morphine Equivalent Dose (MED) Limit: <= 90 mg/day
Morphine Equivalent Dose (MED) Required: Yes
- Quantity Limit: limit maximum 6 EA PER 1 day(s)
- Step Therapy: Pain Narcotic: Opioid:
ST Multiple Generics
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