- QL (1 per Rx);
- PA Applies
- Prior Authorization: PA_APPLIES
- Cluster Headache:
Age Requirement: >= 18
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Headache Specialist;Neurologist;Pain Management Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
Migraine Prevention:
Age Requirement: >= 18
Duration: 3 Month(s)
Documented Diagnosis: Yes
|