- Step Therapy: Neurology: Epilepsy:
ST Single Generic
- Neurology: Epilepsy:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Type(s): Epilepsy
Used as Adjunctive Treatment: No
Duration of Failure or Adjunctive Treatment with Other Antiepileptic Product: >= 4 week(s)
Documented history of persisting seizures after titration to highest tolerated dose of each AED.: Yes
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: Medication History
Positive Response to Therapy Required for Reauth: Yes
Treatment for Age 17 years or older: No
Treatment for Age 1-16 years old: No
History of >= to 30 day trial of other AED required: No
Reapproval based on response: Yes
- Quantity Limit: limit maximum 6 EA PER 1 day(s)
- Prior Authorization: Neurology: Epilepsy:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
|