- Quantity Limit: limit maximum 3 EA PER 1 day(s)
- Quantity Limit: limit maximum 90 EA PER 30 day(s)
- Pain Narcotic: Opioid:
Age Requirement: >= 11
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Type(s): Chronic Pain
Used for Cancer Patients: No
Around-The-Clock Analgesic Required: Yes
Morphine Equivalent Dose (MED) Limit: N/A
Morphine Equivalent Dose (MED) Required: No
- PA Applies
- Osteoarthritis: OA of the Knee:
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Elapsed Duration Since Previous Course of Therapy: N/A
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