- May be covered under Medical Benefit.
- Prior Authorization: Lennox Gastaut Syndrome (LGS), Neurology: Epilepsy:
Documented Diagnosis: Yes
Age Requirement: >= 6
Duration: 1 plan year
Reauthorization Required: Yes
Migraine:
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 1 plan year
Reauthorization Required: Yes
- Prior Authorization: PA_APPLIES
- ST Applies
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