- Quantity Limit: limit maximum 192 EA PER 365 day(s)
- Substance Abuse: Opioid Dependence:
Duration: 14 Day(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Negative Test for Opioids: No
Required Time Duration Abstaining from Opioids: N/A
Rehabilitation Program Required: No
Policy Specifies Induction or Initiation of Therapy: No
Documented Diagnosis: Yes
Induction Period Specified: No
- Step Therapy: Substance Abuse: Opioid Dependence:
Step Applies
- Prior Authorization: Substance Abuse: Opioid Dependence:
PA Applies
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