- Prior Authorization: Neurology: Epilepsy:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
- Step Therapy Exists in PA
- Approved Indications and Usage Guidelines: 1. Diagnosis of partial onset seizures, myoclonic seizures or primary generalized tonic-clonic seizures; AND 2. Medical justification must be provided why patient cannot take generic levetiracetam tablets or liquid. Authorization Limit: Length of Benefit.
- Neurology: Epilepsy:
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Diagnosis Type(s): 1 of Myoclonic Seizures;Partial-Onset Seizures;Primary Generalized Tonic-Clonic 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: 1 of Chart Notes;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
- Step Therapy: Neurology: Epilepsy:
ST Single Generic
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