- Pain Narcotic: Opioid:
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Pain Management Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Type(s): Chronic Pain
Used for Cancer Patients: Yes
Around-The-Clock Analgesic Required: No
Morphine Equivalent Dose (MED) Limit: N/A
Morphine Equivalent Dose (MED) Required: No
- Prior Authorization: ADHD:
Documented Diagnosis: Yes
Age Requirement: >= 6
Duration: 1 plan year
Reauthorization Required: Yes
- Prior Authorization: ABSSSI:
Documented Diagnosis: Yes
Duration: 1 Month(s)
- PA Required
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