- Prior Authorization: PA Applies
- Prior Authorization: Dravet Syndrome, Lennox Gastaut Syndrome (LGS):
Documented Diagnosis: Yes
Age Requirement: >= 1
Duration: 12 Month(s)
Reauthorization Required: Yes
Neurology: Epilepsy:
Documented Diagnosis: Yes
Age Requirement: >= 1
Duration: 1 plan year
Reauthorization Required: Yes
- Quantity Limit: limit maximum 5 mL PER 30 day(s)
|