- Prior Authorization: Substance Abuse: Opioid Dependence:
PA Applies
- Step Therapy: Substance Abuse: Opioid Dependence:
Step Applies
- Quantity Limit: 224 each per 14 days retail
- Substance Abuse: Opioid Dependence:
Age Requirement: >= 18
Duration: 7 Day(s)
Specialist Required: Yes
Medical Test Required: No
Specialist Type(s): 1 of Addiction Psychiatrist;Emergency Medicine Specialist;Pain Management Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 7 day(s)
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
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