Health Net
Lucemyra (lofexidine)
Drugs for Addiction : Drugs for Opioid Addiction
  • 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