- Step Therapy: ST_APPLIES
- Prior Authorization: PA Required
- Prior Authorization: Pseudo-Bulbar Affect:
Documented Diagnosis: Yes
Duration: 3 Month(s)
Reauthorization Required: Yes
- Pain Narcotic: Opioid:
Duration: 24 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Diagnosis Type(s): 2 of Chronic Pain;Moderate to Severe Pain
Used for Cancer Patients: Yes
Around-The-Clock Analgesic Required: Yes
Morphine Equivalent Dose (MED) Limit: N/A
Morphine Equivalent Dose (MED) Required: No
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