- Prior Authorization: PA Required
- Step Therapy: ST_APPLIES
- Quantity Limit: 2 units per 1 day(s).
- 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
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