- Step Therapy: Neurology: Epilepsy:
ST Single Generic
- Step Therapy Exists in PA
- Prior Authorization: Neurology: Epilepsy:
Documented Diagnosis: Yes
Age Requirement: >= 6
Duration: 1 plan year
Reauthorization Required: Yes
- 1. FDA Approved Indications: a. Adults: Adjunctive therapy in the treatment of partial seizures. b. Children: Adjunctive therapy in the treatment of partial seizures in children 6 to 17 years. 2. Health Net Approved Indications and Usage Guidelines: a. Diagnosis of partial seizures, AND b. Failure or clinically significant adverse effects to Trileptal. 3. Authorization Limit: Length of benefit.
- Neurology: Epilepsy:
Age Requirement: >= 6
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Diagnosis Type(s): Partial Seizures
Used as Adjunctive Treatment: No
Duration of Failure or Adjunctive Treatment with Other Antiepileptic Product: N/A
Documented history of persisting seizures after titration to highest tolerated dose of each AED.: No
Lack of compliance as a reason for treatment failure has been ruled out: No
Documentation of treatment failure due to intolerable side effects.: No
Supporting Documentation Requirements: Chart Notes
Positive Response to Therapy Required for Reauth: Yes
Treatment for Age 17 years or older: No
Treatment for Age 1-16 years old: Yes
History of >= to 30 day trial of other AED required: No
Reapproval based on response: Yes
- Quantity Limit: limit maximum 4 EA PER 1 day(s)
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