- Quantity Limit: limit maximum 3 EA PER 1 day(s)
- Prior Authorization: Diabetic Peripheral Neuropathy:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Post-herpetic Neuralgia:
Documented Diagnosis: Yes
Duration: 12 Month(s)
- Step Therapy: Post-herpetic Neuralgia:
ST Single Generic
- Diabetic Peripheral Neuropathy:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Post-herpetic Neuralgia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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