- Quantity Limit: Maximum quantity of 93 per 31 Day(s). Maximum quantity 3 patches per day.
- Prior Authorization: Post-herpetic Neuralgia:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Post-herpetic Neuralgia:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Prior authorization required. Member should try alternative(s) before submitting a prior authorization. If approved, covered at appropriate tier under the member's pharmacy benefit.
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