Anthem Blue Cross (HMO, PPO, EPO) |
Valtoco 5 MG Dose (diazepam) |
Drugs for the Nervous System : Drugs for Seizures /Personality Disorder/Nerve Pain |
- Quantity Limit: 10 blister packs per 30 day(s).
- Cluster Seizure/Seizure Emergency:
Age Requirement: >= 6
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Prior Authorization: Cluster Seizure/Seizure Emergency:
Documented Diagnosis: Yes
Age Requirement: >= 6
Duration: 1 year(s)
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