| Anthem Blue Cross (HMO, PPO, EPO) |
| Gralise 30-Day Starter Pack (gabapentin) |
| Drugs for the Nervous System : Drugs for Seizures /Personality Disorder/Nerve Pain |
- Post-herpetic Neuralgia:
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Step Therapy: Post-herpetic Neuralgia:
ST Single Generic
- Quantity Limit: 78 tablets per 365 day(s).
- Prior Authorization: Post-herpetic Neuralgia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
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